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GUIDELINES FOR THE TREATMENT OF
TRAUMATIC BEREAVEMENT IN
INFANCY AND EARLY CHILDHOOD
DRAFT
Alicia F. Lieberman, Ph.D.
Nancy Compton, Ph.D.
Patricia Van Horn, J.D., Ph.D.
Chandra Ghosh Ippen, Ph.D.
Child Trauma Research Project
University of California San Francisco
c Lieberman, Compton, Van Horn & Gosh-Ippen
Draft: Please do not circulate without permission of the authors
Unpublished Draft – Please do not quote or circulate without permission of the authors.
Contact person: Alicia F. Lieberman, Ph.D., tel. 415/206-5377, e-mail: alicial@itsa.ucsf.edu
July 2002
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Version 15
Guidelines for the Treatment of Traumatic Bereavement
in Infancy and Early Childhood
Alicia F. Lieberman, Nancy Compton, Patricia Van Horn, and Chandra Ghosh Ippen
Child Trauma Research Project
University of California San Francisco
Although we know that after such a loss the acute state of mourning
will subside, we also know we shall remain inconsolable and will
never find a substitute. No matter what may fill the gap, even if it be
filled completely, it nevertheless remains something else. And actually
this is how it should be. It is the only way of perpetuating that love
which we do not want to relinquish.
Sigmund Freud
The death of someone we love is the most painful emotional experience faced by
human beings, an event that changes our psychological landscape because, without the
person that we loved in unique and specific ways, our personal world can never be the
same again. Such a loss acquires cataclysmic dimensions when a child loses a parent
because children focus a vast amount of emotional energy on their parents as their main
source of love and security. Younger children are particularly affected because they are
almost completely dependent on the parents for their sense of security and wellbeing.
The death of a young child’s parent is always premature because it is caused by
accidents, violence, or an untimely disease. As Furman (1974, p. 102) stated, “There are
no peaceful deaths for parents of young children. Whenever we merely say ‘his parent
died’, we leave out the inevitable horror and tragedy that such a death entails”. Nobody is
truly prepared for it, least of all the child, who finds himself suddenly bereft of the person
who organized his sense of physical and mental wellbeing. The younger the child, and
the more involved the parent who died was in the child’s caregiving routines and daily
rituals, the more disorganizing the impact of the death on the child’s psychological
functioning. The child suffers a failure of the developmental expectation that the parent
will be reliably available as a protector, with concomitant injury to the integrity and
continuity of his sense of self (Bowlby, 1980; Pynoos, Steinberg & Piacentini, 1999).
When the parent’s death occurs suddenly and violently, and especially when the
young child is a witness to it, the emotional impact of the death is immeasurably
compounded by the circumstances in which it occurred. The child is overwhelmed by the
scenes of fighting and distress, body damage, loud sounds, agitated movements, and
specific smells that precede and occur during the death. The parent’s protection fails
when the child is most in need of it, and the child’s helplessness and fear are magnified
when he confronts the immobile and unresponsive body of the dead parent. After the
parent dies, other stressful and traumatizing events may occur, including the sight of
blood or the maimed body, the arrival of the police and/or medical personnel, efforts to
assist the injured, the grief reactions of other witnesses, and the child’s separation from
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the parent’s body. These experiences are encoded as intrusive memories that interfere
with the child’s ability to mourn, because the child cannot remember the parent without
also remembering and becoming intensely distressed by the specific manner of the death
(Pynoos et al., 1999). Bereavement and acute anxiety become inextricably intertwined
because the child is simultaneously suffering from the loss of the parent and from
unmastered fears about the circumstances surrounding the death (Furman, 1972).
These considerations suggest that a parent’s death, regardless of its circumstances,
can be conceptualized as a traumatic experience when it occurs in the child’s first five
years life, before the child has established an autonomous sense of self that is relatively
independent of the parent’s protection. The death of a parent, in itself, comprises what
Bowlby (1980) called “the trauma of loss”. The continuum of traumatic experience
depends on the interplay between the circumstances of the death, whether or not the child
witnessed the death, and the child’s developmental stage during the course of infancy and
early childhood. When the parent died at the end of a protracted illness that allowed for
some anticipatory guidance, the child did not witness the death, and the child had some
prior understanding of the nature of death and is capable of some self care, the traumatic
experience consists of an internal collapse in the cohesiveness and continuity of the sense
of self at the loss of protection and security afforded by the dead parent. When the death
is violent and unexpected and the child witnesses it, the collapse of the sense of self is
more acute and complete because the child is flooded by uncontainable anxiety caused by
the sensory overload from the stimuli that accompanied the death, intrusive memories,
and pervasiveness of traumatic reminders that maintain the experience of the death
continually present for the child.
The parent’s death often leads to drastic changes in family life that may introduce
additional stresses in the child’s life. The security of the child’s attachment to the
surviving parent is often negatively affected because that parent may become emotionally
unavailable through self-absorption in mourning and the pressure of attending to changed
life circumstances, and/or because the child blames that parent for failing to prevent the
death. Changes in family composition may occur when, for example, a relative comes to
live with the family to help with the crisis or when a parent feels unable to care for the
child and sends him to live elsewhere. Changes in daily routine are particularly stressful
for young children, both because they represent a break in predictability and because they
remind the child of how the parent did things with the child when he or she was alive.
These secondary stresses and other adverse life circumstances have additive negative
effects on the child’s emotional health, and may lead to a confluence of co-morbid
conditions, such as traumatic stress disorder, anxiety, separation anxiety, and depression
(Rutter, 1985). As a result, treatment modalities must be multifocal in order to maximize
predictability and respond to the range of child responses. The treatment of bereaved
young children must incorporate a range of approaches depending on the individual
circumstances of the death and the child’s reaction to it, with grief and trauma work
integrated and calibrated in response to the child’s and family’s needs (Pynoos & Nader,
1993). The traumatic circumstances surrounding the death can recede in the child’s mind
when the anxiety responses are consistently addressed, facilitating the child’s work of
mourning the loss of the parent (Furman, 1974).
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These guidelines describe approaches to the treatment of infants, toddlers and
preschoolers who experienced the death of a parent or other primary caregiver in a range
of circumstances. Although addressed to clinicians for the purpose of therapeutic work,
components of the guidelines may also be useful for teachers and caregivers seeking to
provide emotional support to bereaved children.
The guidelines include common reactions to loss in infancy and early childhood,
assessment and treatment approaches, concrete strategies for helping children cope with
the loss, and clinical vignettes. The suggestions for intervention are informed by an
integration of psychoanalytic theory and attachment theory with social learning and
cognitive-behavioral interventions. The reference section includes basic sources as well
as more recent contributions that were helpful in developing these guidelines, including
bereavement manuals for the treatment of older children. The guidelines may also be
extended to other forms of early loss, including the death of a sibling or grandparent. For
the sake of brevity, the word “parent” is used to denote a caregiver with whom the child
has a primary attachment relationship, regardless of the biological origins of it.
An important question that must be addressed by every practitioner providing
treatment to bereaved children is: “What skills do I need to be of help to the child and his
family?” Working with very young children who are grieving for a lost parent presents
extraordinary challenges even to experienced clinicians. Witnessing a child’s profound
suffering can evoke feelings of helplessness and despair when the clinician faces the
impossibility of granting the child’s most intense wish -- bringing the parent back. The
clinician’s own sorrow over past losses and anxiety over traumatic experiences are
invariably awakened and may be enacted in unconscious ways. These enactments
frequently include anger at the child’s current caregivers for their perceived failings in
supporting the child, and vivid rescue fantasies of adopting the child or finding a new and
perfect family for him. The emotional burden of treating bereaved young children calls
for considerable personal maturity as well as specific knowledge of the emotional needs
of infants, toddlers and preschoolers and understanding of the effects of trauma and loss
on early development. Consistent access to emotionally supportive consultation or
supervision is essential because it helps the clinician find and retain therapeutic clarity in
the course of this difficult work.
The guidelines are written for clinicians with experience in treating young
children or who are in training to acquire this experience. The basic premise is that the
clinician’s emotional availability and empathic responsiveness must be grounded in a
solid clinical background and a working knowledge of early development. It is important
not to underestimate the toll on the clinician’s emotional wellbeing that this work entails,
and to establish stable and knowledgeable sources of support.
The course of grief and bereavement, always subjected to wide individual
variations, is particularly unpredictable in infancy and early childhood because it is
deeply affected by the child’s constitutional strengths and vulnerabilities, the quality of
surrogate caregiving, and the changing circumstances of the family, including the
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availability and quality of environmental supports. For these reasons, our focus is less on
recommending specific intervention techniques than on promoting a therapeutic attitude
informed by knowledge of developmental principles and the effects of trauma and loss.
These guidelines endeavor to convey a state of mind about how to treat early traumatic
bereavement rather than to prescribe specific interventions. The clinician’s own
creativity, experience, and emotional maturity are essential ingredients in using these
guidelines to structure what is always a uniquely individual therapeutic effort to engage
the child and the family in weaving a joint narrative about the parent’s death.
PARENTAL LOSS IN INFANCY AND EARLY CHILDHOOD
In infants, toddlers and preschoolers, the loss of a parent has such a devastating
impact on the child's sense of personal safety that it is often impossible to say where grief
ends and trauma begins. Both processes are intricately connected with each other.
Whether one or the other predominates depends on a combination of external and internal
circumstances. External circumstances include the manner of the death, the
foreknowledge the child had of it, whether the child witnessed it, and how the child was
told about it. Internal circumstances involve the child’s developmental stage, cognitive
skills, and emotional resources. It is safe to say, however, that traumatic stress responses
are commonly observed in conjunction with grief reactions and prolonged mourning in
young children who lost a parent at an early age.
For children in the first five years of life, the death of a parent can be considered a
traumatic loss regardless of the circumstances in which it occurs because young children
need to trust that the parent will be reliably available and protective in order to develop a
sense of physical and emotional integrity. When an attachment figure dies, the child loses
intimate patterns of interaction that organize key developmental domains and constitute
the building blocks for the child’s sense of self. The loss produces intense and longlasting grief, and represents a risk factor for healthy development unless the child is
supported in the protracted process of mourning. This process involves overlapping
stages of grieving, relinquishing the hope that the parent will return, integrating the
memories of the lost parent into an ongoing sense of self, and turning to another
attachment figure that can provide renewed hope in the trustworthiness of intimate
emotional bonds. These overlapping processes comprise the work of mourning.
The child-parent relationship in the early years shapes the child’s sense of self.
The child acquires a sense of self through regulation of bodily rhythms (e.g., eating,
sleeping, elimination), modulation of emotion (e.g., experiencing and expressing a range
of feelings, managing distress, coping with anger and frustration), formation and
socialization of interpersonal relationships (e.g., developing attachments and forming a
hierarchy of attachment relationships, learning to differentiate and relate differently to
acquaintances and strangers, internalizing cultural norms for what is expected, what is
permissible and what is forbidden in social exchanges), and learning from exploration of
the environment, including an increasingly accurate discrimination of what is safe and
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what is dangerous in the child’s particular physical environment and in the background of
the family’s social and cultural expectations.
For infants, toddlers, and preschoolers, these processes unfold in the context of
their relationships with the parents and/or a small number of emotionally salient
individuals, whom the child identifies as the providers of a secure base for self-regulation
and exploration of the world. These relationships are created and buttressed by daily,
repeated interactions that for the very young child involve every facet of bodily
experience, including feeding, diapering, bathing, and soothing, and for the older child
involve disciplining and teaching in addition to social play. The memories that the young
child has of the parent are essentially interactive: the mental representations consist of the
way the parent did things with the child. When the parent dies, the child loses the parent’s
protective intervention and the sense of security in interactive exchanges that emerges
from such protective intervention (Bowlby, 1980; Pynoos et al., 1999).
Attachment figures are not interchangeable for the child. Each of them
constellates a particular set of emotionally laden experiences that cannot be readily or
painlessly transferred to another caregiver. For this reason, young children’s response to
the death of a parent involves grief and bereavement even when the other parent
continues to be available to them. No two loves are ever the same, either for children or
for adults. One loved person cannot replace another even while providing comfort for the
loss. Children can eventually allow another adult to perform the caregiving functions that
were once the prerogative of the dead parent, and they will come to love a surrogate
caregiver when the process of mourning unfolds in developmentally appropriate ways.
However, the unique ways of feeling associated with the dead parent will be neither
forgotten nor replaced.
The most detailed descriptions of young children’s initial responses to parental
loss date back about half a century, when such gifted child observers as Anna Freud and
Dorothy Burlingham (1943, 1974), Rene Spitz (1946a and 1946b), John Robertson
(1952, 1953) James and Joyce Robertson (1971), Christopher Heinicke and Westheimer
(1966) and John Bowlby (1958, 1960, 1979, 1980) documented children’s reactions both
in film and in written transcripts of their moment-to-moment observations. These early
studies focused on infants’, toddlers’ and preschoolers’ responses to prolonged separation
from their mother or parents due to war, hospitalization, maternal incarceration, or family
circumstances. These records remain unsurpassed in their emotional power and
immediacy. As described by John Robertson,
“It takes an exercise of the imagination to sense the intensity of this
distress. (The young child) is as overwhelmed as any adult who has
lost a beloved person by death. To the child of two with his lack of
understanding and complete inability to tolerate frustration it is really
as if his mother had died. He does not know death, but only absence;
and if the only person who can satisfy his imperative need is absent,
she might as well be dead, so overwhelming is his sense of loss.”
(Robertson, 1953).
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The accuracy and perceptiveness of these early observations continue to be
vouchsafed by later studies of children whose parents have died (Adam, 1973; Anthony,
1971; Furman, R., 1973; Furman E., 1974; Ilan, 1984; Mahler, 1961; Eth & Pynoos,
1985; Pynoos, Steinberg, & Wraith, 1995; Pynoos, Steinberg & Aronson, 1997; Raphael,
1982; Osofsky, Cohen & Drell, 1995). Infants and toddlers may respond with intense
grief to both prolonged separation and loss because in both situations the emotional
impact of the parent’s absence is immediate and severe. However, as children mature, the
finality of death becomes an increasingly central factor in organizing the mourning
process because children become better able to understand this concept.
While there is universal agreement that children suffer following a parent’s death,
there has been much theoretical disagreement about the meaning of this suffering. Rutter
( 1981) stressed the importance of factors other than maternal care in modifying
children’s responses to maternal loss. Some writers maintain that children under five
years of age are incapable of mourning because they have neither the cognitive
mechanisms necessary to understand the finality of death nor the emotional maturity
needed to tolerate the protracted process of relinquishing a beloved person before
establishing new affectional ties (A. Freud, 1960; Spitz, 1960; Nagera, 1970). Relying on
ethological evidence from animal studies as well as direct observation and clinical
treatment of bereaved young children, other writers have argued that grief and mourning
occur even in the absence of mature cognitive and emotional skills (Bowlby, 1960,1980;
Furman, 1974; Raphael, 1982).
These long-standing theoretical disagreements persist, and many clinicians remain
reluctant to recognize the enduring pain and longing caused by parental death in young
children. One argument used to justify this reluctance is that children’s expressions of
grief are often brief and interspersed with play and interest in other activities
(Wolfenstein, 1966), giving rise to the wishful adult thinking that the child has
“forgotten” about the death and is not “really” mourning. This is far from the case: young
children’s cognitive and emotional immaturity involves attention span limitations and
the need for “time off” from demanding psychological endeavors, but these respites are
invariably followed by recurrent bouts of immersion in the loss experience.
Another source of reluctance in accepting children’s enduring experience of loss
is a misunderstanding of the concept of resiliency, which is mistakenly thought to mean
that children recover quickly and completely from stressful events. The most current
views of childhood resiliency suggest instead that the concept is best understood as an
interactional process (Cicchetti & Rogosh, 1997; Rutter, 1993). The child is able to
mobilize his inner resources to cope with stressful situations through the support and
encouragement of trusted adults. The grief caused by the parent’s death is a central
emotional event that has repercussions for every aspect of the child’s functioning, and
that calls for sustained efforts on the part of the adults who care for the child to mitigate
its negative impact on the child’s personality development. In other words, the child’s
constitutional potential for resilience in the face of grief, stress, and trauma needs to be
actualized through the adult’s ability to provide age-appropriate environmental support.
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TRAUMATIC LOSS
When the parent’s death occurs suddenly or violently, and particularly when the
young child is a witness to it, an additional layer of traumatic stress is superimposed on
the already taxing work of mourning. If the child is present at the time of death, the
child’s coping resources are overwhelmed by terrifying visual images, overpowering
auditory stimuli, autonomic arousal, and other sensory experiences that trigger extreme
fear and disorganization (Pynoos, 1994). Little is known about dissociative responses in
the first years of life, but it is likely that they occur when the child is neither capable of
engaging in the self-protective responses of flight or fight nor able to rely on the parent
for protection from danger. Seeing the injured or dead parent can become a source of
intense fear and distress. As a result, the sensory experiences accompanying the parent’s
death are likely to become intrusive mental images that interfere with the young child’s
work of mourning because they are incompatible with the emotional closeness evoked by
the parent prior to the death
Even when the child is not present during the parent’s sudden or violent death,
vicarious traumatization is possible from hearing repeated descriptions of the event and
observing the intense distress of family members. Children as young as 18 months of age,
and perhaps younger, may form mental images on the basis of verbal descriptions,
particularly if the topic is one of great emotional importance to them. These mental
images may borrow features from the distraught faces and agitated voices of the bereaved
adults surrounding the child. The suddenness of the death compounds the severity of the
emotional impact because the bereaved child and family members have not had time to
prepare themselves for the loss.
REACTIONS TO PARENTAL LOSS IN INFANCY AND EARLY CHILDHOOD
Manifestations of grief and mourning
Children’s responses to separation and loss include cycles of intense distress,
emotional withdrawal, anger and emotional detachment that may recur at periodic
intervals during a prolonged period of time. It must be remembered that there are marked
individual differences in the appearance, duration and intensity of these reactions.
However, children’s grief responses are not markedly different from those shown by
adults (Bowlby, 1980). The differences emerge in the developmental understanding of
the nature, causality and finality of death, and this understanding affects the course and
resolution of mourning (Furman, 1974; Pynoos et al., 1995).
Protest. The initial response is almost always one of intense protest. Starting at
about the middle of the first year of life, children respond to the loss of a parent with
persistent crying, searching, and alternating between accepting and rejecting the efforts of
other adults to comfort them. This behavior can last for two or three days. It decreases in
intensity but recurs sporadically for several days thereafter, particularly at night and
during transitions such as bedtime. The intensity and duration of the responses increase
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with the emotional closeness of the relationship and its centrality in the child’s everyday
life.
Example. Sammy, age 2, responded with intense crying when he was told by his
aunt that “daddy died because a bad man hurt him very hard and he can’t move
anymore”. For the next two days, he went around the house calling out “daddy, daddy”,
and looked up expectantly whenever the door bell rang, only to cry again when he saw
that the person coming in was not his father. He repeatedly went to his father’s study,
insisted on sitting there for long periods of time, and fought off efforts to take him out
while crying intensely at the same time. He pushed away his aunt’s hand when she tried
to feed him, and only accepted to be fed by his mother. He refused going to bed, cried for
a long time before falling asleep, and woke up repeatedly during the night, calling out for
his father.
Sadness and emotional withdrawal. After this initial phase of intense protest, the
child’s behavior loses intensity, but a mood of quieter sadness, withdrawal and lethargy
takes its place. The child is still oriented to the parent and awaiting a reunion, as
evidenced by isolated questions about when the parent is coming back, holding on to an
object that belonged to the parent, or insisting on having something done in precisely the
way the parent did it. These responses highlight the interactive, relational nature of the
memories the child holds of the parent. The child only finds “empty space” in the
activities that once formed the framework for the child’s relationship with the parent. The
child brightens up when hearing a sound or seeing a sight that may signify the parent’s
return, only to sink back into apathy when this hope is not fulfilled. When symbolic play
has been achieved, the child’s play may reflect themes of separation and reunion.
Example. Sammy, 2 years old, showed a marked decrease in activity level after
the two days of intense protest described above. He looked forlorn, avoided eye gaze, and
interrupted the short bouts of play with his older cousin suddenly to say, in a low tone of
voice: “daddy”. He continued to look up expectantly when the door bell rang or the door
opened, but instead of crying he looked down sadly on seeing who came in. He burst into
intense crying when his mother could not immediately find his security blanket, and
clung to it once it was given to him. He moved slowly, and refused to go to the park. He
insisted on seeing his mother at all times, and banged on the door crying when she went
to the bathroom. He now allowed his aunt to feed him, but ate as if it were an effort and
showed no interest in the food. This behavior lasted for two weeks, and diminished
gradually.
The effort to bring the parent back is sometimes expressed in indirect ways, and
only an observer who is keenly attuned to the child’s experience might notice the
meaning of the child’s behavior.
Example. Donna, 30-month-old, insisted on cleaning the furniture using an old
sock a few months after her mother’s death. This was a cherished activity that mother and
child had regularly done together. The child burst into tears and could not be consoled
when her caregiver, not understanding the meaning of her behavior, kept taking the sock
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away and giving her a cleaning cloth instead. This little girl eventually resorted to hiding
a sock in her closet and used it to clean furniture when she thought nobody was watching
her.
Young children express sadness over the death intermittently, interspersing it with
periods of apparent immersion in other pursuits. This phenomenon has been labeled
“short sadness span” (Wolfenstein, 1966), and reflects children’s limited capacity to
tolerate sustained negative affect. Some children can be remarkably self-observant in this
regard.
Example. Annalise was almost three years old when her mother died. On the oneyear anniversary of the death, she listened quietly as her grandmother said to her: “I am
sad today because I am thinking of your mother. Do you still miss her?” She thought for a
moment and then answered: “No… It takes a long time”. This child demonstrated an
impressive ability to think of herself as missing her mother in the past and comparing this
frame of mind with her current subjective experience of not missing her. She returned to
openly missing the mother a few weeks later, when she spoke wistfully about her coming
back some day.
Intensification of normative developmental anxieties. The child’s developmental
stage is a key element in how children respond to the parent’s death (Eth & Pynoos,
1985). Specifically, young children’s grief and mourning need to be understood in the
context of developmentally normative anxieties. The prevailing normative anxieties for
children under age five are separation anxiety and fear of losing the parent’s love and
approval. Separation anxiety is prevalent between six months and two years of age and
stems from a rudimentary concept of object permanence, or knowledge that objects
continue to exist even when they are no longer within the person’s perceptual field. Fear
of losing the parent’s love and approval is related becomes increasingly more dominant
in the preschool years, as the child begins to achieve object constancy (integration of
positive and negative feelings towards loved ones), starts to internalize adult standards
for right and wrong, struggles to curb unacceptable impulses and adapt to social
expectations, and acquires the rudiments of a moral conscience (Fraiberg, 1959).
With the parent’s death, these fears are no longer relegated to the realm of fantasy
but acquire a terrifying concreteness. The child has learned that what he most dreads-losing the parent and the parent’s loving support-- can actually occur. In searching for an
explanation to the dead parent’s disappearance, children find reasons that match their
developmental understanding of causality, such as “my mommy didn’t love me” or “I
was bad and daddy left”. Very young children, who do not yet see themselves as the
cause for events and are years away from understanding abstract cause-effect relations,
can develop a sense of always-impending doom because catastrophic events can happen
unpredictably and without reason.
Children’s anxiety responses are not limited to the parent who died. The child’s
behavior towards the surviving parent is also affected because the child fears losing that
parent as well. Separation anxiety and fear of losing love are manifested in fear of being
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left, clinginess, excessive concern about the parent’s whereabouts, persistent demands for
attention, ingratiating behavior, and pervasive worries about the parent’s well-being.
Some children develop somatization symptoms such as stomachaches, headaches, nausea
and vomiting. Other children refuse to engage in normal activities because they become
overly afraid of getting hurt, or ask anxious questions about the dangerousness of
everyday activities. These symptoms can be understood at several levels. They may
signal a fear that what happened to the parent will happen to the child as well. They may
also ensure that the child is not left alone and receives much-needed attention and
reassurance.
Anger is another recurrent feature of young children’s grief reaction, and it is
often manifested in aggressive behavior. The aggression is often without visible cause
and may be directed at a variety of targets indiscriminately. It is likely that the child is
angry at the absent parent and discharges this unmanageable feeling on the object that is
closest at hand. Sometimes the child responds with aggression towards the self, in the
forms of pulling one’s hair, self-biting, self-hitting, and hitting the head against the
pillow, the floor or the wall.
Regressions in developmental functioning are common among grieving young
children. They may revert to baby talk after having mastered language, or may lose
sphincter control after being toilet trained. Sleep disturbances are very frequent, including
refusal to sleep alone, difficulty going to sleep, night wakings, and nightmares. Temper
tantrums may reappear in preschoolers who have outgrown this common feature of the
toddler years. The child may lose the capacity to tolerate everyday frustrations, and
respond with inconsolable sobbing to seemingly minor mishaps. Usually, the skills that
were most recently acquired are lost first. These functional regressions tend to be timelimited, but may mushroom if ridiculed or ignored and must be taken as indications that
the child needs additional emotional support to regain developmental momentum.
New fears. The parent’s death represents the loss of the developmentally
appropriate protection the child needs to feel secure and confident in her everyday life.
Without the ability to rely on the parent as protector, the child may develop multiple new
fears. The specific fears usually consist of more intense and intractable versions of
developmentally expectable fears, such as fear of strangers, fear of the dark, fear of being
alone, fear of loud noises or looming objects, and fear of separation (Bowlby, 1973).
When the child witnessed the parent’s death, the new fears may reflect the child’s
response to traumatic reminders of sights, sounds, and smells that the child experienced
during the event. These fears may also represent children’s worry that they will be hurt
and killed in the way the parent was.
Example. Pamela, age 3, witnessed her mother being knifed to death by the
mother’s boyfriend. She developed an intense fear of knives and of sharp objects, hiding
behind her grandmother when she saw kitchen knives and crying until they were put
away.
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Affective-cognitive processes
Psychological processes set in motion by the parent’s death may not be readily
categorized through specific symptoms. In addition to readily identifiable behaviors such
as those described above, children’s thought patterns may become reorganized after the
parent’s death and brought into line with the child’s fantasies and wishes.
Idealization of the dead parent is a common occurrence. The child may remember
the dead parent as all good and all knowing. Children may harbor a recurrent fantasy that
if the parent had not died, none of the difficulties encountered by the child or the family
would occur, and life would be without any stress. A 3-year-old responded to a broken
toy with the sad comment: “If daddy were here, he’d fix it”. This response may be
accompanied by anger at the surviving parent, who is then perceived as bad, inept, or
incompetent for being unable to live up to the standards attributed to the dead parent.
Fantasizing a reunion with the dead parent is another frequent response that is
also common among adults. In adults, the wish for a reunion may be expressed in the
religious belief that loved ones will meet in heaven after they die, or in dreams that the
loved one is alive again. Children often hold simultaneous beliefs that the parent is dead
and that the parent is alive and will return, and may describe in detail what will happen
when the parent comes back The wish for a reunion may also be expressed through play
scenes where the dead parent and the doll child are together doing something pleasurable,
or where the dead parent comes to the child’s help in a difficult situation. For example,
3-year-old Annalise said to her grandmother: “Maybe my mommy will get tired of being
dead and come back”.
Magical thinking plays a major role in shaping the young child’s understanding of
the parent’s death. Toddlers and preschoolers have not yet learned to differentiate reliably
between subjective and objective reality. As a result, feeling angry at someone can be
equivalent in their minds to hurting that person. Magical thinking is a byproduct of young
children’s egocentric perception of causality, which involves seeing themselves as the
root cause of the events that affect them. Engaged as they are in developmentally
appropriate struggles with angry impulses and affect regulation, it is easy for young
children to assume that something in their own behavior caused the parent’s death. A 3year-old whose mother had died a year earlier said wistfully: “If I had not gone to school,
I could have helped her”. Another 3-year-old whispered: “Maybe I hit him too hard”
when told of his father’s sudden death the day after a spirited wrestling game. These
fantasies about causing the parent’s death may coalesce into a persistent self-image as
dangerous and aggressive.
Self-blame and guilt often take the form of efforts to work out how the death
could have been avoided if one had done things differently. These responses are frequent
among children as well as adults. This widespread phenomenon led Erna Furman (1974)
to hypothesize that assuming responsibility for the death may serve a defensive function
against an even more frightening alternative: being helpless to control life events. If given
the choice between two evils, children as well as adults may choose a specific instance of
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personal failure, no matter how devastating, rather than open themselves to the idea of a
world where terrible events may happen at random, without the possibility of fending
them off through effective action.
Older preschoolers (four- and five-year olds) may contend with their helplessness
in preventing the parent’s death by taking on excessive responsibility, fantasizing on the
actions they could have taken to bring about a different outcome, and berating themselves
for their imagined failure to act effectively.
Example. Emma, age 4, witnessed a stranger knifing her mother in an attack on
the street when she was three years old. She regressed in her use of language for many
months, and was referred for treatment when she became aggressive with peers at her
preschool. During the first weeks her play with dolls consisted of enacting the attack
scene again and again as a child doll looked on. After several weeks of this play, the
outcome started to change. On succeeding weeks the child doll hit the attacker with a toy
car, with a plastic cup, and with a wooden cube. Another time the doll child ran away and
called the police. When the therapist commented that the doll child was trying very hard
to help her mommy, Emma whispered: “I didn’t help my mommy”.
Attribution of omnipotent power to important figures in the child’s life is another
manifestation of the need to control events. Toddlers and preschoolers perceive their
parents as all-knowing and all-powerful. They take for granted that parents can do
whatever they want, and that parental behavior is caused by parental desires. Learning
that parents may be forced to do something against their will is a gradual achievement in
reality testing that is beyond the grasp of toddlers and preschoolers. As a result, young
children may interpret the parent’s death as a deliberate abandonment. In their minds, the
parent left them because she or he wanted to. This interpretation of events can easily
become linked with the worry that the child did something wrong and deserved to be left.
Such a perception can become the foundation for the fear of being unlovable, anxiety
about being left, and hopelessness about the future.
The attribution of power to important adults may also involve the fantasy that the
surviving parent can make the deceased parent come back. A 3-year-old girl screamed at
her mother: “Make my daddy come back!” Disappointment and anger may become
prevailing features of the child’s relationship to the surviving parent for failing to prevent
or remedy the death.
Caregiver reaction to the death: Effects on the child
The death of a child’s parent represents a loss to other family members as well.
While the child is grieving for the lost parent, the other adults closest to the child are
grieving for a lost spouse, son or daughter, and/or sibling. Paradoxically, the adults most
deeply affected by the parent’s death are also the people most needed by the child to cope
with the death. Because young children develop in the context of intimate relationships,
the surviving parent is most often the person best positioned to help the child cope with
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the death. At the same time, this parent may be so immersed in grieving as to be
emotionally unavailable to the child.
Mourning involves absorption in one’s personal pain. As the adults grieve, they
may engage in expressions of intense pain without being aware of their impact on others.
While there are large individual and cultural differences in the expression of grief, adults
who feel intense emotional pain may scream, sob loudly, engage in agitated movements,
pull at their hair, tear at their clothes, throw themselves against walls, or hit themselves or
others. They may say things that express profound hopelessness, such as “what will we
do without him”, or “I don’t want to live anymore”. Children are keenly aware of these
responses because they use social referencing – learning how to feel and behave from
watching the behavior of trusted adults – as a guide for their reality testing. Witnessing
scenes of unmodulated grief is often terrifying for young children because they infer from
the parent’s response that a catastrophe has occurred and that their world has collapsed.
After the immediate period of grief subsides, adults resort to a range of
mechanisms to allow them to cope with the enduring pain of a loved one’s death.
Ambivalence may emerge, for example, in the form of blaming the dead person for
behaving in ways that contributed to the death (e.g., “he wouldn’t have had a heart attack
if he ate better and exercised more”; “she insisted on driving in the rain in spite of
everybody’s advice”). There may be efforts to downplay the person’s emotional
significance to the survivors (e.g., “he worked so hard that he was not around very much,
so we got used to his absence”). Alternatively, the dead person may be idealized to such a
degree that only positive memories are allowed expression, with a concomitant
prohibition -- either implicit or explicit -- on speaking about episodes that involved
negative feelings (e.g., “she was an angel, always sweet, giving, and caring, and she
never said or did anything that would hurt others”).
Grieving adults may not notice or give serious consideration to the pain of a small
child. Even when they are aware of it, the adults may feel too emotionally depleted to
respond sensitively to the child’s grief. They may resort instead to self-protective
attempts to minimize their own sorrow in witnessing the child’s pain, including telling
themselves that young children “do not understand” death and therefore cannot be
lastingly affected by it, or that childhood resiliency will allow the child to quickly resume
normal functioning. The parent may offer misleading explanations that do not correspond
to what they child overhears or to what the child has seen. When both the surviving
parent and the child witnessed the murder of the dead parent, the child’s very presence
may be a reminder of the horror they went through, and the parent may enter a
“conspiracy of silence” in an attempt to establish some emotional distance from the event
(Pynoos et al., 1999).
These adult beliefs and responses are widely held, but they are not helpful to the
child and need to be recognized for what they are: well-meaning but ultimately damaging
efforts to avoid the inescapable recognition that young children’s pain at the parent’s
death is intense, deep, and has lasting consequences for the child’s trust in the endurance
of loving relationships.
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Adult responses to the death may stand in stark contrast to the child’s own
reactions, leading to a mismatch between the adult’s and the child’s emotional needs
about how to process the mourning. For example, the child might express intense anger at
the dead parent for leaving just when the bereaved adult is at the height of idealizing the
lost loved one. These discrepancies in response might create emotional alienation
between the child and the surviving parent, who cannot find a common vocabulary for
mourning. The child will be immeasurably helped in the mourning process if the adults
give her permission to express feelings that are different from their own and to accept
these feelings without reproach.
Such permission to feel is paramount to the child’s wellbeing because the
approval of the parent is of primary importance for young children. In pursuit of
approval, children may force themselves to feel and believe what the adult expects them
to. This can lead to serious distortions in the child’s personality development. Adults
often tell children “pious lies” that contradict the child’s direct knowledge of the parent’s
death as well as what he overhears from the adults’ conversations. When the child sees or
hears one thing and is told another, he is torn between his trust in his own perceptions and
the age-appropriate tendency to rely on adults for an understanding of reality. The result
is often an inner split, where the child holds two mutually exclusive versions of reality.
Consciously, the child abides by the “official story”, i.e., the version of events provided
by the adults. Unconsciously, the child holds on to the facts as he knows them and gives
them his own personal interpretation, which is often distorted by cognitive immaturity in
the understanding of causality and the self-referential tendencies of this age (Bowlby,
1973).
Children may also downplay or suppress their grief reactions in order to comply
with the adults’ wishful belief that children are resilient by nature and that they will
recover quickly if they are not reminded of their loss. They may act “as if” they have not
noticed the dead parent’s absence or “as if’ they have come to terms with it. This
suppression or hiding of bereavement can set off a series of defensive processes that
interfere with the child’s healthy emotional functioning, both in the moment and in the
course of the child’s development.
Young children need to rely on their parents or attachment figures to make sense
of what happens to them. For this reason, the treatment of traumatic bereavement in
infancy and early childhood should optimally include the active involvement of the
child’s surviving parent or primary caregiver. The parent is a crucial ally in the child’s
treatment. Forming a therapeutic partnership with the parent on behalf of the child
enables the therapist to appraise the strengths and vulnerabilities of the child’s primary
relationships and daily environment, and to use this assessment to inform and guide
treatment. When the therapist provides the surviving parent with emotional support at a
time of great need, the therapist also builds a context for expanding the parent’s
awareness of the child’s grief reactions, facilitating conversation between parent and
child about the parent who died, and suggesting activities to promote the restoration of
hope and renewed openness to emotional intimacy and pleasurable experiences.
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Guidelines for bereavement work with the surviving adults on behalf of the child are
provided in the sections on assessment and treatment.
THE ASSESSMENT PROCESS
The assessment of an infant, toddler or preschooler whose parent has died
calls for an integrated, multi-systemic approach. Young children lack the cognitive and
linguistic maturity to provide comprehensive verbal self-reports, and much of the
information about the child’s condition needs to be elicited from the surviving parent and
other caregivers, who might not be knowledgeable or accurate informers of the child’s
experience. Whenever possible, information from one source needs to be confirmed
through information from other sources and through direct observation of the child.
Young children are remarkably adept at reenacting traumatic events accurately using
dolls and other props, and do so either spontaneously or when guided by a clinician
(Gaensbauer, 1996; Pruett, 1979; Scheeringa & Gaensbauer, 2000).
The child’s experience of the death must be systematically ascertained by asking
the adult informers for details of what the child saw and heard and what the child was
told. The assessment must also include the child’s developmental history, present
functioning, and current circumstances, including the child’s relationship with the parent
who died and with the current primary caregivers.
The assessment is not only a time to gather information but also an opportunity
for early therapeutic intervention with the child and the family. Optimally, the assessment
period can offer a safe framework for expressing emotion and for testing out which
treatment strategies are most likely to be effective given the characteristics of the family
members.
The circumstances surrounding the parent’s death need to be carefully elucidated
because children’s behavior is profoundly affected by situational factors. This is a
delicate task because asking about the events surrounding the death necessarily re-evokes
emotionally charged memories for the informant. The surviving adults may need to deny
or amend important aspects of what the child saw and heard, or give more socially
acceptable versions of what really happened. Their own level of psychological function
and their experience of the death will influence their reliability as reporters. The assessor
needs to be aware of pressures on the child to “not feel what he feels and not know what
he knows” (Bowlby, 1980).
When the deceased parent was also the child’s primary caregiver, history taking
can be particularly painful because it may quickly become evident that it is no longer
possible to learn about important aspects of the child’s life. In this case, it is important to
assess whether other people in the child’s life can supply this information without
undermining the surviving parent’s sense of being a valued informant about the child.
The informant’s responses also provide valuable insights into his or her sensitivity to the
child’s experience, and these insights can be incorporated into the formulation of the
treatment approach.
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While a thorough assessment is often a useful starting point for treatment, it
should not be allowed to interfere with timely therapeutic intervention, which must be
implemented without delay in crises and other urgent situations. When a child’s parent
dies suddenly or in traumatic circumstances, the first order of business is to provide
immediate support to the child and to the bereaved adults. A prolonged assessment
process is actually contraindicated in these conditions because there is a danger that
gathering information will take priority over helping the child and the caregivers to
grieve and to process the death. Skillful clinicians can use crisis work and immediate
therapeutic intervention as a source of useful information about the child’s and family’s
strengths and vulnerabilities.
Grief work with the family is very often a necessary prerequisite to the beginning
of the child assessment and treatment. While the family might seek services ostensibly
because of the child, the adults may be in such a state of shock and dismay that their
ability to support a child-centered assessment and treatment process may be
compromised. In such situations, it is important to use a flexible format that incorporates
individual sessions with the adults focused on their own emotional needs (Osofsky et al.,
1995).
In less urgent circumstances -- for example, when a child is referred for treatment
several months after the parent’s death -- the clinician may choose a more leisurely
approach to assessment. The length and content of the assessment is necessarily
determined by practical circumstances, such as the regulations of the mental health clinic,
the requirements of the funding sources, and the financial situation of the family. The
managed care system places limitations on the duration of the assessment and treatment
that are driven by financial rather than clinical considerations. These conditions demand
considerable resourcefulness on the part of the clinician to provide adequate
psychological care in the face of external constraints.
A “best practices” approach suggests that a thorough assessment may require
between three and five 45-minute sessions (Zero to Three, 1994). The assessment should
include history, direct observation of the parent-child interaction, and evaluation of the
child using an interactive approach that may include play using props selected to elicit the
child’s experience of the parent’s death, standardized procedures, and/or other modalities
such as drawing. The child evaluation should provide information about the child’s
sensorimotor functioning, language capacity, level of symbolic play, and expression and
modulation of affect. This information will help to frame an approach to treatment that is
tailored to the child’s capabilities.
ASSESSMENT DOMAINS
The assessment should focus on the factors that affect the child’s bereavement
process. When an assessment is successfully completed, the assessor should have
clinically rich information about the domains described below.
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1. The child’s emotional, social, and cognitive functioning.
The assessment should include an evaluation of the child’s functioning in these domains
both before and after the parent’s death because the loss is likely to create major
disruption in one or more of these areas. Assessment of the child’s functioning in the
emotional, social and cognitive domains serves as the basis for determining whether the
child is suffering from a diagnosable clinical condition. Areas of inquiry are outlined
below.
a. Temperamental propensities. The child’s constitutional characteristics are
manifested in the expression and regulation of emotional responses to a variety of
situations, including novelty, transitions, and stress. The nine temperamental dimensions
described by Alexander Thomas, Stella Chess, and their colleagues (Thomas, Chess, &
Birch, 1968; Thomas, 1980; Thomas & Chess, 1984) continue to have great clinical
relevance. These dimensions are: activity level, regularity of biological rhythms,
tendency to approach or withdraw from new situations, adaptability to change, intensity
of response, sensitivity to stimulation, predominant mood (positive or negative),
distractibility, and persistence in pursuing a goal. A sample of useful questions is
provided below.
 When the child is confronted with a new person or a new situation, how does she
respond?

Does the child have a consistent schedule for eating, sleeping, and toileting?

How does the child respond when going from one activity or place to another?

What is the child’s mood usually like?

When the child is upset, how does she calm herself or use other people to help her
calm down?
b. Social-emotional functioning. This domain involves the quality of the child’s
relatedness to others as well as her capacity to function autonomously with a manageable
amount of anxiety. There are broad cultural variations in the value that is assigned to
behaving autonomously, and the assessor should be prepared to take them into account
when evaluating how well an individual child is coping with grief and trauma. The
following brief developmental guidelines are suggested for screening purposes.

By six to eight weeks of age, a baby is generally interested in gazing at the face of
the caregivers, often for long periods of time. She smiles at her caregivers, and
broadens her own smile if her caregiver smiles back. She may recognize a
caregiver’s imitation of her early cooing sounds, but generally won’t be able to
reproduce her original sound in response. She will be interested in a friendly
stranger’s face, but will turn in preference to the face of familiar caregivers.

By four to six months, a baby becomes less willing to accept unfamiliar people.
Until then, she may have been willing to be handled by anyone who would care
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for her gently, but now the baby may protest at being held by anyone except a
familiar caregiver. She is beginning to understand cause and effect and to know,
for example, that she can make someone appear by crying. She actively uses
behaviors such as crying, smiling, and verbalizing to bring her preferred
caregivers closer.

By nine months, most babies have achieved a level of motor independence that
allows them to crawl toward and away from their caregivers. They use social
referencing to help them make important judgments about the world. For
example, a 10 month-old baby who has fallen down may look to his mother to see
if she is upset before he cries. Babies of this age are beginning to understand
person permanence (“Mommy and daddy still exist even if I can’t see them.”),
and this capacity means that they can tolerate brief periods of waiting for a
caregiver to appear to tend to their needs. They also have enough experience of
the world that they have begun to form expectations about whether they will
succeed or fail at what they try, and whether they anticipate praise from those
around them. Separations may begin to be difficult as the child understands, from
his own motoric prowess, that people he loves can leave him.

Toddlers aged 12-15 months are still working to master the concepts of object and
person permanence. Because of their increased motor skills, they are increasingly
free to explore the environment and to use their caregivers as a secure base for
exploration. Play with peers may begin to move from parallel play to more
reciprocal interactions.

Toddlers between 18 months and two years old are expanding their sense of
autonomy by exploring on their own and by actively resisting their caregiver’s
wishes. They make conflicting demands from their caregivers, wanting the
freedom to explore and make choices but also the sense of safety that comes from
limits that protect them from hurting themselves or spiraling emotionally out of
control. They may have abrupt shifts in mood, changing quickly from elation to
rage and from defiance to cuddliness.

As children approach the age of three, they become less oppositional and more
likely to imitate their caregivers’ behavior. They use symbolic play to express
increasingly complex emotional ideas, and by the age of three can generally act
out imagined experiences. Their increased ability to explore the world and their
more active imaginations mean that they also may develop fears and phobias at
this age. A 3-year-old should be able to use the caregiver’s help to prepare for
expectable events that may frighten her. For example, this may involve attending
to the caregiver and talking about her feelings when told, as they walk around the
block together, that the house where the big dog lives is only a little ways up the
street, and that the dog might bark. Peer relations are important. Preschoolers use
their relationships with both peers and caregivers to learn to modulate their strong
feelings and to express them in words or through play rather than acting them out.
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From three to five years of age, children consolidate and broaden these skills.
They begin to form hierarchies of relationships outside their immediate families
and, using their early caregiving relationships as templates, can use a wider
variety of adult figures to help them modulate their emotions and to teach them
new things. They are able to separate from primary caregivers with increasing
ease. They engage in increasingly complex symbolic play and, by the age of six,
are beginning to be more concerned with the rules that govern relationships.
c. Cognitive functioning. A young child’s cognitive functioning is integrated with
his social-emotional functioning, and is strongly affected by that foundation. If a child’s
environment is normally stimulating and if the child was relating to others in ageexpectable ways prior to the loss, his cognitive functioning is probably also adequate.
Gross cognitive delays (for example if a child of two is not using any language) should be
investigated further. Medical examinations are important to rule out problems with
hearing or vision as the cause of a cognitive delay.
Memory of the parent as a discriminated figure in the child’s experience is
necessary to establish the child’s response to the parent’s death. Two types of memory
are generally described in the literature: nondeclarative or implicit memory, and explicit
or declarative memory (Schachter, 1987). Implicit memory is largely unconscious, it is
exemplified in responses to conditioning, and has been experimentally demonstrated in
fetuses (DeCasper & Spence, 1986) and newborns (Papousek, 1967). Explicit memory is
conscious and expressed verbally and behaviorally. The earliest age at which is was
demonstrated experimentally is 9 months, when infants were shown to repeat
behaviorally events that occurred the day before (Mandler, 1990). After 36 months
children can produce full verbal narratives of traumatic events, and children between 2836 months are able to describe stressful events coherently (Terr, 1988; Howe, Courage &
Peterson, 1994; Peterson & Bell, 1996). There are clinical reports of children using one-,
two- or three-word sentences between 18 and 28 months to refer to frightening or
traumatic events.
If clinicians are concerned about a child’s development, the references at the end
of this booklet can be used for a more complete discussion. If the clinician believes that a
bereaved child’s development is seriously impaired, a comprehensive developmental
assessment will help to plan for the most productive ways to work with the child.
Because loss and trauma can cause regression in skills, it is important to understand how
the child was functioning before the loss as well as how she is functioning now.
2. The child’s relationship with the deceased parent.
This domain involves the place of the dead parent in the child’s life, including
areas of pleasure and comfort as well as areas of conflict. Losing the parent who provided
physical caregiving has a direct impact on the somatic experiences of infants and
toddlers, who depend on the primary caregiver to be fed, bathed, diapered, dressed,
ministered to when hurt or distressed, and taught about bodily functions. When the parent
who died had a central role as the child’s playmate or teacher, the domains of pleasurable
activity, exploration, and learning are affected as well. In addition to the global grief
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evoked by the parent’s death, children tend to grieve over the specific activities that were
most intimately associated with the lost parent.
For this reason, daily routines can become a constant reminder of the parent’s
death for young children. The discrepancy between how the parent performed these
routines and how the current caregiver is doing it evokes acute pain that can be expressed
through angry rejection, including aggression towards the current caregiver. The less
verbal the child, the more likely these reactions will seem inexplicable to the caregiver
because the child cannot articulate the source of his dissatisfaction. The two examples
below illustrate the range of these reactions.
Example. A nine month old baby, Lorraine, cried frantically on being placed in
her crib by her loving aunt. Her now deceased mother used to lay the child on her
stomach; the aunt placed her on her back. At nine months, Lorraine was at an age where
separation anxiety and predictability of caregiving routines begin to be very salient
developmental issues, and the change in bedtime routine became a trigger for her distress.
The aunt knew that Lorraine’s mother had placed the child on her stomach when putting
her to sleep, but disagreed with this practice in light of the new pediatric guidelines to
prevent Sudden Infant Death Syndrome (SIDS) by laying children on their backs. The
clinician suggested a compromise: putting Lorraine on her stomach when placing her on
the crib, and then turning her over once she fell asleep. After two weeks of this routine,
Lorraine accepted being placed directly on her back when put on the crib.
Example. Reed, aged 2, hit his grandmother in the face and threw his breakfast
cereal on the floor for the first week following his mother’s death, screaming: “plane!
plane!” His mother had made him hot oatmeal every morning, and played a “here comes
the airplane” game while feeding it to him. Reed’s grieving and harrassed grandmother
had neither the emotional frame of mind nor the energy to pursue this practice. She
thought she would collapse in tears if she re-enacted her deceased daughter’s loving
routine. Instead, she delegated to her 15 year old daughter the task of feeding Reed
breakfast. This young woman continued to give Reed cold cereal, but played the airplane
game in feeding it to him. Reed adjusted to this change after some protest, but his
appetite for breakfast declined markedly after his mother’s death.
One can learn much about the child’s relationship with the dead parent by
learning about the specific activities that they did together. In turn, learning about these
activities provides the basis for recommendations that are tailored to restoring a sense of
safety and predictability to the child. The questions suggested above for assessing
socioemotional functioning can serve as guidelines in asking more specific questions
about the ways in which the child related to the deceased parent, and in identifying other
people with whom the child has important relationships.
3. The child’s network of relationships: Presence of a new attachment figure.
Young children need to depend on at least one loving and supportive adult, who
can provide a secure haven during the mourning process and function as a surrogate
caregiver in the developmental domains previously attended to by the deceased parent.
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The assessment period needs to involve an exploration of the child’s relationships
with the surviving parent and other caregivers as well as with siblings. In moving from
assessment to treatment, the clinician can use this information to assist the surviving
parent in developing new routines that will help the child sustain comforting memories of
the deceased parent. For example, if the deceased parent routinely read stories to the child
at bedtime and always ended with a particular story or phrase, it may be effective for the
surviving parent to adopt that routine. This routine can then be used as an opportunity to
talk about the dead parent, and how that parent would wish to still be doing this activity
with the child.
4. What the child knows: identifying traumatic reminders of the death.
The assessor needs to know how the child was told about the death, when, and by
whom. This information should include any discrepancies that may exist between the
facts of the parent’s death and what the child was told about it.
Sometimes the child will have witnessed the parent’s death, or will have been the
one to discover the parent’s body after death. In such cases, the child may have
information that other caregivers do not have about the death. It is essential to probe
carefully for traumatic reminders that will trigger intense distress in the child (Pynoos,
1992). Unless these reminders are identified and systematically addressed during
treatment, the child’s traumatic stress responses will be misunderstood as “irrational” by
the adults and the child may be forced to re-experience situations that aggravate the
traumatic response. The surviving parent’s thoughts and feelings about the child’s
experience and about the specific traumatic reminders should be carefully assessed to
elicit concerns and to plan a collaborative course of action about how to address the
child’s experience in the course of treatment.
At the end of the assessment, the clinician should have an inventory of the
traumatic reminders and loss reminders that elicit distress in the child. This inventory is
an essential guide to understanding and addressing effectively the child’s responses in the
course of treatment both within the sessions and in every day life.
Example. Natalie, age 4, saw her father lying on the floor, dead from a drug
overdose, when she was 3 years old. On the third child-parent session with the clinician
one year later, she suddenly interrupted her play while her mother was talking about her
father and laid down on the floor with her eyes closed. Natalie’s mother did not notice
this behavior and continued talking. The therapist motioned towards the child, asking the
mother: “What do you think she is doing?” The mother answered that she did not know.
Addressing both mother and child, the clinician said: “Natalie, I think you are showing
your mom and me when you saw your daddy dead on the floor”. Natalie continued to lie
on the floor with her eyes closed, but nodded almost imperceptibly in agreement. The
mother whispered, almost to herself: “She remembers”. The therapist said: “It is so sad
that he could not get up any more.” Natalie continued to lie motionless. The therapist
added: “We can remember together how scary it was when your daddy could not move
any more”. Natalie opened her eyes, and the therapist said: “We are so happy that you are
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OK and you can move and get up”. Natalie seemingly ignored this statement and
approached some toys. Such moving on to a different pursuit is a common response when
children feel that their communication has been understood and that they need a respite
from an emotionally charged topic. Natalie’s memory of her dead father had been clearly
established among all three participants in the session, and this scene became a basis for
recurrent therapeutic work with Natalie’s perception of her father’s death.
5. Continuity versus disruption of daily routines. The child’s mourning process is
facilitated if the physical and social environments remain substantially unchanged. As
described in section 2 above, daily routines are inextricably connected with the child’s
relationship with the dead parent, and every effort should be made to minimize abrupt
changes in how the child is cared for on a daily basis. The child’s work of mourning is
made more difficult when financial strains and changes in the family’s circumstances
necessitate a move to a different residence, relocation to a different town, and/or the loss
of familiar people and routines. The pressure on the child of adjusting to new conditions
is then compounded by the lessened emotional availability of the adults as they also strive
to cope with the changed circumstances.
6. Cultural and family traditions and beliefs regarding death and dying.
This involves learning how these traditions and beliefs have been transmitted to
the child, including the child’s participation in funeral rituals. This area often needs
immediate assessment, especially when consultation or treatment are sought immediately
after the death. For example, the clinician may be asked for advice about whether the
child should attend the funeral. The clinician’s role in such cases is to consider with the
family what will happen at the funeral (e.g., Will there be an open casket? Is the family or
community tradition one that includes open keening or weeping at a funeral?), and
whether observing or taking part in such rituals will be comforting or overwhelming to
the child. These issues are discussed at greater length in the section on Concurrent
Treatment Modalities.
7. Family childrearing values and plans to care for the child.
Bereaved families are often overwhelmed by the need to find a substitute
caregiver that will take the place of the deceased parent. Different family members might
have drastically different ideas about what should happen with the child. Cultural values
can play a major role in determining who should become the child’s caregiver, but there
might be clashes between family members who hold different priorities. Often, the adult
who is is singled out as a possible caregiver by other family members might be unwilling
or unable to accept this responsibility. For example, the brother of a deceased parent may
be considered as the natural parent substitute by the child’s grandparents, but the
brother’s wife might refuse to accept this plan because she believes that she will bear the
brunt of raising the child. Alternatively, the grandparents may want to take care of the
child, but other family members might feel that the grandparents are too old or frail to do
this successfully. When outside agencies such as Child Protective Services are involved,
the question of who will take care of the child tends to become even more contested, and
court proceedings may prolong the uncertainty for many months. The clinician needs a
great deal of patience and tactfulness in negotiating these difficult circumstances. To play
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a helpful role for the child, the clinician must become familiar with the circumstances
listed below.
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Changes in the family circumstances that affect the child’s daily routine;
Availability of an adult who can become a new primary attachment figure;
Previous relationship between this adult and the child;
This adult’s motivation to become the child’s primary caregiver;
This adult’s ability to empathize with the child’s predicament; and
This adult’s sources of support to carry out the caregiving role.
8. The family’s general strengths and vulnerabilities.
All families live in a broader social context that will either sustain them or further
burden them after the loss. For example, if the parent that died was the primary
breadwinner, the family may be in precarious financial circumstances and have to change
patterns of everyday life. The assessor should discuss these matters with the family and
make appropriate referrals for legal assistance and case management. The assessor should
also evaluate the family’s network of relationships in the extended family, the
neighborhood, and in faith, school, or work communities.
The family’s developmental stage in the life cycle is an important ingredient in
understanding the impact of the death for the family unit. For example, what family plans
and dreams were interrupted or derailed by the parent’s death? The parents of young
children are usually pursuing goals intended to enhance the family’s circumstances or
fulfill developmentally expectable wishes: having another child, graduating from school,
moving to a larger house, going back to work after maternity leave. The financial
pressures or changes in life circumstances may make those goals unattainable, adding an
additional layer of grief to the experience of the death.
DIAGNOSTIC EVALUATION
The information gathered during the assessment provides the foundation of
determining whether the child has a diagnosable clinical condition. Diagnosing a child in
the first five years of life is a difficult endeavor because of the rapid pace of the
development, the central role of emotional relationships in shaping the child’s
functioning, and the child’s responsiveness to situational factors and changes in
circumstances. Young children’s relatively limited behavioral repertoire also means that
the same behavior may express different emotional experiences. For example, a tantrum
may signal either anger or anxiety, or both, depending on the circumstances.
For these reasons, classifying young children in diagnostic categories is fraught
with conceptual difficulties (Emde, Bingham, & Harmon, 1993). At the same time, there
are clinical as well as practical reasons supporting the desirability of a diagnosis. A clear
diagnostic picture can help the clinician establish a clear treatment plan. Establishing a
diagnosis can also be helpful in obtaining payment for services from a variety of thirdparty payers, including those who fund treatment for victims of crime.
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Two diagnostic manuals may be used for diagnostic purposes: the Diagnostic and
Statistical Manual of Mental Disorders–IV (American Psychiatric Association, 1994) and
the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy
and Early Childhood (DC: 0-3) (Zero to Three, 1994).
The most widely used diagnostic manual, the DSM-IV, was conceptualized for
use with adults, adolescents and older children. It does not focus on the developmental
characteristics of infants, toddlers and preschoolers, although elements of it may be
applied with young children as well (Scheeringa & Zeanah, 1995; Scheeringa, Zeanah,
Drell, & Larrieu, 1995; Scheeringa, Peebles, Cook, & Zeanah, 2001). The most relevant
diagnostic categories for bereaved children are Posttraumatic Stress Disorder, one of the
Mood Disorders, and Adjustment Disorder with anxiety, depressed mood, and/or conduct
problems.
DC:0-3 is a nosology of mental health and developmental disorders developed
specifically for use with infants, toddlers and preschoolers. It provides an excellent
framework for assessing young children’s developmental level and the quality of their
primary relationships as the context for making a clinical diagnosis. Its discussion of
children’s responses to parental loss is of great relevance for clinicians working with
bereaved children because it elucidates the criteria for a differential diagnosis of
traumatic response versus bereavement.
Differential diagnosis between bereavement and traumatic response
DC: 0-3 recognizes the clinical overlap between grief and traumatic stress in very
young children. It offers a diagnostic category labeled Prolonged Bereavement/Grief
Reaction, and describes it as a mood disorder in children who have lost a parent or
primary caregiver. It also offers a diagnostic category labeled Traumatic Stress Disorder,
and recommends that this diagnosis should take precedence when there is a clear stress
that is “severe or significant enough, i.e. a specific overwhelming episode or multiple
repeated trauma, associated with the disordered behavior or emotions” (p. 16). The stress
should be of such significant magnitude that the disorder would not be present without
that stress. The categories of Prolonged Bereavement/Grief Reaction or Traumatic Stress
Response should take precedence over other diagnostic categories when a child lost a
parent recently and is showing clinical symptoms. Each of these diagnostic categories is
described below.
Prolonged Bereavement/Grief Reaction
The symptoms that characterize this diagnosis are the following:
1. Crying, calling, and searching for the absent parent, refusing the attempts of others to
provide comfort.
2. Emotional withdrawal with lethargy, sad facial expression, and lack of interest in ageappropriate activities.
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3. Disruption of psychobiological rhythms such as eating and sleeping.
4. Regression or loss of previously achieved developmental milestones.
5. Constricted range of affect.
6. Detachment, in the form of seeming indifference to reminders of the lost person.
7. Extreme sensitization to any reminder of the lost person, or to situations connected
with separation and loss.
Traumatic Stress Disorder
This diagnostic category is characterized by the symptoms described below.
l. Re-experiencing of the loss as evidenced by the following behaviors.
a. Post-traumatic play, defined as play that represents a reenactment of some aspect of
the traumatic event, is compulsively driven, fails to relieve anxiety, and is more literal
and less imaginative and elaborate than is usual for the child.
b. Recurrent recollections of the event outside of play, whether or not accompanied by
distress. For example, a child may repeatedly ask about the parent’s whereabouts
even after being told repeatedly that the parent has died and will not come back.
c. Repeated nightmares.
d. Distress at exposure to reminders of the traumatic experience, such as driving by a
playground where the parent and the child used to spend time together.
e. Episodes with objective features of a flashback or dissociation. For example, a 2year-old who two months after her mother’s death stopped playing suddenly and
stared blankly into space for almost one minute upon hearing the front door of her
house being opened.
2. Numbing of emotional responsiveness, as evidenced by social withdrawal, restricted
range of affect, temporary loss of previously acquired developmental skills, or decrease
and constriction of play.
3. Increased arousal, as shown in night terrors, difficulty going to sleep or falling asleep,
difficulty paying attention, hyper-vigilance, and exaggerated startle response.
4. Fears that were either not present or less intense before the event, including separation
anxiety and fear of the dark.
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5. Aggression towards peers, adults or animals.
6. Other symptoms not present before the event, such as somatic disturbances, motor
reenactments, or sexualized behavior.
DC: 0-3 points out that it may be difficult to make a differential diagnosis
between Prolonged Bereavement/Grief Reaction and Traumatic Stress Disorder because
of the overlap in symptoms characteristic of both conditions. This position echoes the
widely held clinical stance that loss of a parent in infancy and early childhood constitutes
a traumatic experience. DC:0-3 specifies that the differential diagnosis should be made
on the basis of the nature of the symptoms. In Traumatic Stress Disorder, the child shows
a greater tendency towards anxious reenactment of the traumatic loss and compulsive
patterns of behavior. In Prolonged Bereavement/Grief Reaction, the child shows a greater
tendency towards depression and lethargy. The specific symptoms shown by an
individual child may be influenced by the circumstances surrounding the parent’s death,
whether the child witnessed it, the behavior of other adults close to the child following
the death, and child characteristics including temperamental style, developmental stage,
and cognitive and emotional resources.
DC:0-3 also includes diagnostic categories involving disorders of affect, including
anxiety disorders and depression. These conditions are not discussed in the present
guidelines because the recommended diagnoses when the child shows clinical symptoms
after losing a parent are Traumatic Stress Disorder or Prolonged Bereavement/Grief
Reaction. However, symptoms of anxiety and depression need to be carefully
documented because co-morbid conditions are very common both among children and
adults exposed to traumatic experiences (Rutter, 1985).
HOW TO USE THE ASSESSMENT INFORMATION
When the assessment is completed, it is crucial to provide a feedback session that
clearly outlines the different facets of the child’s functioning, including areas of
competence as well as vulnerability. The feedback session will be more successful in
attaining the clinician’s objectives if the information is shared with the family in a
calibrated and timely manner as it emerges in the course of the assessment, rather than
“all at once” during the final assessment session. In this way, the feedback session can be
an opportunity for revisiting themes and weighing alternatives that were introduced
earlier and do not take the family by surprise.
The decision to recommend treatment is a central aspect of the feedback session.
If treatment is considered necessary, the clinician must present it in light of the family’s
wishes, needs and concerns in order to have a chance of implementation. Resistance to
treatment is a very understandable response because people often prefer to be reassured
that the child is doing well and that whatever problems exist are normal and will
disappear in the course of time. The rationale for recommending treatment needs to avoid
blaming the family at all costs, even when the behavior of family members is likely to be
contributing to the child’s problematic behavior. Instead, the recommendation for
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treatment can be framed in the context of the difficult circumstances that the family is
experiencing. Defensiveness is a common response in the face of blame, and people are
far more receptive to the message that their circumstances are sufficiently taxing that
anybody in a similar situation could use additional support.
The proposed duration of treatment needs to be explicitly discussed at the
beginning of the assessment or during the feedback session at the latest. If the setting and
financial circumstances allow for open-ended treatment, the clinician should engage the
family in a discussion of what improvements can be expected before treatment is brought
to an end. Many clinical settings and insurance plans offer only a specific number of
treatment sessions, and this must be clarified from the beginning. The clinician should
also discuss possible alternatives if additional treatment is needed after this time.
The assessor needs to understand that the surviving parent might be unable to give
priority to the child’s treatment needs because of the strain of mourning, personality
characteristics, and/or concrete stresses, such as financial worries or other factors.
Empathic support for the family’s circumstances is often the most reliable way of
enlisting the parent’s collaboration on behalf of the child. In this sense, an assessment
well done can become a successful intervention in its own right.
THE TREATMENT PROCESS
TREATMENT MODALITIES
The treatment of infants, toddlers and preschoolers can take a variety of formats.
When the adults caring for the child are so overwhelmed by the loss that their capacity to
understand the child’s needs is jeopardized, grief work with the primary caregivers may
be offered as a first step in helping the child (Osofsky et al., 1995). When the child is
part of the treatment, any one of four treatment modalities are frequently used. These
modalities may shift in the course of treatment in response to changing clinical
circumstances. The circumstances in which the different modalities are used are
described below.
Child-parent model
This modality involves joint meetings with the child and the parent, as in infantparent or child-parent psychotherapy (Fraiberg, 1980; Lieberman & Van Horn, 1998;
Lieberman, Silverman & Pawl, 2000). It is based on the premise that young children rely
on their attachment figures to make sense of what happens to them. The model assumes
that the treatment of traumatic bereavement in infancy and early childhood should
optimally include the active involvement of the child’s surviving parent or primary
caregiver as a crucial ally in the child’s treatment.
The goal of child-parent psychotherapy is to enhance the child’s mental health by
fostering emotionally supportive and developmentally appropriate interactions between
parent and child. When a young child’s parent dies, there is a very strong likelihood that
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the emotional quality of the child’s attachment to the surviving parent will be negatively
affected. The child loses trust in the surviving parent, who is unable to alleviate the
child’s pain or to produce the wished-for return of the dead parent. The child’s longing
for the dead parent and loss of trust in the surviving parent’s good will and competence
are often manifested in behaviors that are difficult to understand or tolerate, including
refusal to accept the parent’s care and affection, unpredictable outbursts of anger,
defiance or sullen refusal to comply with parental requests, and intense mood swings
which may intermingle clingy and needy behavior with aloofness and aggression. Some
children become intensely depressed, showing sadness, lethargy, and a loss of vitality and
enjoyment of everyday pursuits. Nothing the parent does seems to please them. These
behaviors can become an additional emotional burden on bereaved parents, who must
cope with their own grief while also enduring the loss of cherished qualities in the
relationship that they had with their child before their spouse’s death. The result may be a
profound emotional alienation and loss of intimacy in the child-parent relationship, in
spite of the parent’s best efforts to be helpfully available to the child.
Child-parent psychotherapy aims at helping the surviving parent understand the
child’s difficult behavior as an expression of the child’s pain, find supportive ways of
speaking about the death and assuaging the child’s fears, and create an emotional
atmosphere that fosters between parent and child a joint acknowledgement and working
through of the intense feelings associated with grief and mourning. The child-parent
psychotherapist focuses on the emotional tone of the parent-child interactions, targeting
for change negative attributions and conflict-laden exchanges and reinforcing areas of
interpersonal harmony in the dyad. The format of joint sessions offers the therapist the
opportunity to intervene in the moment to facilitate the communication of feelings
between parent and child and to enhance parental empathy for the child’s experience. The
therapist may also add individual sessions with the parent on an as-needed basis to gain a
better understanding of the parent’s experiences and the family’s circumstances.
In general, the younger the child, the more preferable it is to conduct joint childparent sessions because a secure relationship with the surviving parent represents the
child’s best hope for long-term successful adjustment. A central challenge of child-parent
psychotherapy is the demand on the clinician’s versatility to be simultaneously attuned to
the child’s and the parent’s distinct subjective experiences as well as to the emotional
tone of their interaction. Sometimes the parent’s psychological needs are expressed with
such urgency that it is difficult for the clinician to feel that adequate attention is paid to
the child’s needs. Other times the reverse is true. These inevitable oscillations in
therapeutic focus do not detract from the goal of treatment if the clinician keeps clearly in
mind that the work is ultimately intended to benefit the child by improving the childparent relationship. Over the course of the treatment, there needs to be a recurring
emphasis on how the parent’s experience affects the child. The message that the
treatment is for the child, and that the parent is an indispensable partner in the treatment
but not the primary recipient of it, can be conveyed in a variety of ways. Most
particularly, the sessions are built around toys, play, and age-appropriate materials such
as books and drawing tools so that the child-oriented focus of the work is graphically
stated at all times.
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Example. Danny lost his beloved father in a car accident when he was 2 ½ years
old, and was referred for treatment by his pediatrician six months later because his
mother reported a regression in the use of language, intense separation anxiety, and sad
affect. The initial session with the mother showed that she was very concerned about
Danny’s sadness but unable to speak to him about the father’s death for fear of breaking
down in tears and frightening him. The treatment consisted of joint child-mother sessions
in which the therapist spoke gently about the sadness Danny and his mother felt because
the father was dead and could not come back. The therapist facilitated the elaboration of
this theme through play with a family of dolls and with toy animals in which Danny took
the lead in playing out repeated scenes of a car crash, the father doll being broken, and
the child doll rescuing him and bringing him back to life. The therapist put words on
these mostly monosyllabic play sequences, and spoke about how much Danny and his
mother wished this rescue could happen with Danny’s daddy as well. The emphasis on
this unattainable wish allowed the mother to join Danny in expressing sadness, and she
wept in his presence for the first time while the therapist spoke about how mommy and
Danny were sad together. This play theme was interspersed with periods of anger and
defiance in which Danny was aggressive towards the mother and the therapist.
Throughout the different facets of treatment, the mother was enabled by the therapist to
tell Danny that she would take care of him even when they were sad or angry at each
other. Within six months, Danny regained his original liveliness and was using words to
express feeling, although sadness and longing for his father and intermittent bouts of
aggression continued on an episodic basis. His mother reported that she was now able to
reminisce with him about the father, and that Danny spoke spontaneously about his father
in her presence.
Family therapy model
This model includes the presence of siblings, with or without the caregiver. The
inclusion of siblings in therapeutic sessions with a young child can be extremely helpful.
This is particularly the case when the loss of both parents has been sustained or the
children have been placed with unfamiliar caregivers. The presence of a sibling,
especially in the beginning of treatment, can be very reassuring to a young child.
Discussions can be facilitated surrounding the loss of the parent(s) in a manner in which
the grief process is shared. As the treatment progresses, decisions may be made about the
desirability of continuing with this format or shifting to a different format. A thoughtful
illustration of a family therapy model incorporating joint and individual treatment with
traumatized and bereaved young twins and grief work with their grandparents is provided
by Osofsky et al. (1995).
Example. Jossy, age 5, and Lillian, age 3, lost both of their parents suddenly and
were placed together in foster care. Jossy was protective of her younger sister and
referred to her as “manita”, a Spanish term of endearment for a sister. The children were
very vigilant of each other’s whereabouts and protested when they had to spend time
away from each other. The children were treated jointly because both of them needed
treatment and to provide separate treatment to would have been stressful for both. In a
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family model, they were able to use psychotherapy to grieve the loss of their parents, and
express their fears that nobody would take care of them. This was a realistic fear because
the children were placed in foster care and it was unclear what their future would be. The
therapist spoke about how Carmen (the child welfare worker, whom the children knew
and liked) was looking very hard for a family that could take care of them. In the
meantime, the therapist said, their foster mother was taking care of them and the therapist
was helping them to remember their mom and dad, who loved them very much and
wanted to take care of them but could not because they died. In collateral sessions, the
therapist worked with the foster mother to develop ways of helping the child with their
grieving outside the sessions. When new caregivers were found for the children, the
therapist helped to prepare them for the transition by meeting jointly with the children
and the foster mother and helping them to say good-bye to each other.
Individual child psychotherapy/ collateral sessions with parent
This modality is recommended in two situations: 1) when the surviving parent is
unable to tolerate a therapeutic focus on the child because of his or her own grief or
character structure; and 2) when the child is unable to express grief feelings in the
presence of the bereaved parent because of fear of hurting the parent or because of fear
of the parent. In such circumstances, the individual treatment of the child must be
supplemented with the ample use of collateral sessions with the parent or caregiver, with
the goal of promoting the adult’s increased understanding of the child’s needs.
Example. Marcus, age 2, was seen individually for treatment following the
murder of his mother by his father, who committed suicide several days later. After the
mother’s remains were discovered, the family became concerned that Marcus may have
witnessed her murder. It was clear from the assessment that the boy’s grandmother, who
became his new primary caregiver, could not bear to think about her daughter’s death or
to discuss it with the child. In her grief, she averted her gaze and turned away from
Marcus whenever he spoke about his mother. The clinician realized that the grandmother
would not be able to support Marcus as he sorted out his memories and feelings about
losing his mother. For this reason, the clinician provided individual treatment to the child
while offering collateral meetings to the grandmother, continually re-assessing the
grandmother’s capacity to tolerate thinking about her daughter’s death as the treatment
progressed. Very gradually, the grandmother became a participant in the treatment
sessions with Marcus, began to tolerate knowing what the child had witnessed, and was
able to provide him with empathic support in his distress.
Developmental guidance
This modality consists of individual sessions with the bereaved parent to provide
emotional support and developmental guidance about the child’s needs, without direct
treatment of the child. The interventions have the goal of helping the parent to support the
child during the mourning process. The therapist provides the surviving parent with
emotional support at a time of great need, expands the parent’s awareness of the child’s
grief reactions, helps the parent acquire ways of speaking with the child about the parent
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who died, and encourages the parent to engage in activities with the child that will
promote emotional intimacy and pleasurable experiences. This modality also provides an
opportunity to educate the parent or caregiver about possible symptoms that may emerge
in the future, and that may signal the need for clinical intervention with the child.
Developmental guidance is usually indicated when the child is not presenting
clinical symptoms, the parent is attuned to the child’s needs, and the parent is willing and
able to carry out the therapist’s recommendations. In such benign conditions, individual
treatment of the child may be actually contraindicated because it can introduce an
extraneous influence in the mourning process. This includes the possibility of an
iatrogenic reaction to the termination of treatment, when the child is confronted with the
seemingly arbitrary end of an emotionally important relationship with the therapist.
Example. Rebecca, age 3, lost her father after a long battle with colon cancer.
Three months later, Rebecca’s mother sought consultation after she read an article in a
popular magazine about the importance of the early years as the emotional foundation of
a child’s personality. She told the therapist that she was worried about how Rebecca
would develop without a father, and said that she wanted to prevent future mental health
difficulties for her child. The interview with the mother revealed that Rebecca had been
aware of his father’s deteriorating health over the previous year, and that Rebecca’s
maternal grandparents and paternal uncle had stepped in to help the mother in taking care
of the child during this period. Rebecca had been told that her father had died because he
got too sick and the doctor could not help. She was not taken to the funeral, but was told
that her father was in heaven and watched for her from high above the clouds. Every
night her mother went through a bedtime ritual where both spoke to the father and told
him they loved him. They then prayed to God for health and wellbeing, and asked God to
take care of the father. Rebecca played doctor every day, checking the health of her dolls
with the aid of a medical kit, but she did not express worry about her own health or the
health of her caregivers. She asked about her father, but then said to herself, sadly: “He
got too sick and he died”, as if reminding herself that she already knew what had
happened to him. The assessor determined that Rebecca was going through the mourning
process in a developmentally appropriate way, and was helped in this process by the
preparation the family had had for the father’s death and the family’s considerable
psychological strengths and ability to support the child’s grieving. Developmental
guidance was ended after three sessions when the mother stated that she felt better
prepared to watch for possible signs of difficulty in Rebecca.
In general, the choice of modality is guided by three major sets of parameters: the
clinical needs of the child and the family, the parent’s preferences, and the clinician’s
area of expertise, which usually leads to the clinician’s confidence in the greater
effectiveness of a particular approach. In complicated clinical situations, a combination
of modalities may be indicated. For example, infant- or child-parent psychotherapy may
be conducted in conjunction with individual sessions with the child and collateral
meetings with the surviving parent.
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THE THERAPEUTIC SETTING
Home Visiting
Home visits are a very useful setting for the treatment of infants, toddlers and
preschoolers because the home holds memories of the deceased parent that can be used as
vehicles to therapeutic interventions.
Example. A 3-year-old who was unable to speak about her dead mother for many
weeks spontaneously broke the impasse by retrieving a children’s Bible from her room
and telling the therapist: “My mommy gave this to me”. Reading the Bible together
became the initial vehicle for articulating the child’s memories of times she spent with
her mother.
During a home visit the therapist can ascertain whether and how the presence of
the deceased parent is preserved in the home.
Example. A therapist discovered during a home visit two weeks after a parent’s
death that all the photos of the 4-year-old’s mother were placed above the child’s eye
level and out of the child’s reach. The child, who had been pining for her mother, was
soothed when the pictures were placed at eye level for her.
Home visits also provide an opportunity to identify traumatic reminders and offer
important clues about childcare routines.
Example. During a home visit, the therapist found out that a 3-year-old was
continuing to sleep in the same double bed she had shared with her mother before the
mother’s death. This child’s recurrent nightmares diminished markedly when the double
bed was replaced with a child’s bed.
The home also provides an opportunity to see to what extent there is a state of
order as opposed to disarray. Following the death of a loved one, concrete assistance is
sometimes needed to perform basic tasks of daily living such as washing the dishes,
putting away food and doing laundry. Friends and relatives can sometimes be identified
to assist with these tasks.
In spite of their advantages, home visits demands solid institutional support and
therapist commitment because they are more time consuming and emotionally demanding
for the therapist. For these reasons, a clinic playroom is much more common as the
setting for therapeutic work with children.
The clinic playroom.
Although the clinic setting does not afford the clinician the opportunity to collect
all of the information described above, working in the clinic playroom does have some
advantages beyond the obvious one of convenience for the clinician. It allows the
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clinician to provide a safe, consistent frame for the treatment that is free from distraction
and from the comings and goings of others that are not involved in the treatment. These
features cannot always be guaranteed in a home setting. The clinic playroom also allows
for more flexibility in the selection of therapeutic toys, including the use of toy furniture
such as a doll house and the use of a sand tray. Further, the clinic playroom is more likely
to allow the freedom of expression that is the hallmark of psychotherapy, whereas in the
home setting the treatment is sometimes constrained by rules of behavior that parents
reasonably enforce in their homes, such as good social manners and refraining from using
dirty words or aggressive behavior. These modes of expression may have freer rein in
the clinic setting than at home.
Community settings
Community settings (for example a room made available in a preschool or day
care setting) may be the most practical way to provide services to a child. Some children
show symptomatology primarily in the childcare situation, responding angrily to other
children and rejecting the teacher’s attempts to comfort them. Pynoos (personal
communication, 2002) reported the case of a young child who, after his father’s murder,
became aggressive towards the only other boy in his classroom whose father came to pick
him up at the end of the day. Addressing this boy’s behavior as an expression of his wish
for his father to continue picking him up in the setting in which it occurred helped the
child to find more adaptive ways of expressing his distress. Using community settings as
the site for treatment enables the clinician to provide relevant information and
developmental guidance to other people involved in the care of the child.
UNFOLDING AND CONTENT OF THE THERAPEUTIC PROCESS
Treatment Goals
Defining the goals of treatment helps the therapist to maintain a balanced
therapeutic perspective as the treatment unfolds. When the child’s pain is overwhelming,
revisiting these goals mentally helps the therapist remember that, although there are no
short-cuts in the process of mourning, the child’s developmental momentum can serve as
a powerful ally towards restoring a sense of hopefulness and possibility. Some major
goals of treatment are outlined below.
1. Child’s acceptance of the physical reality of the parent’s death.
“The indispensable first step of the mourning process is the individual’s awareness,
comprehension, and acknowledgment of the death of his loved one” (Furman, 1974, p.
50). Young children need help to understand what death means and to accept that the
parent will not return. Both children and adults tend to deny the reality of a loved one’s
death at least temporarily, and young children are more likely to do so because of their
lack of familiarity with the finality of death. Concrete examples, in the form of dead bugs
or birds, are useful to convey to the child this understanding to the child.
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The therapist must give the child the opportunity to experience fully the range of
feelings evoked by the parent’s death by making statements that normalize and support
the legitimacy of the child’s longing, anger and pain. It is essential to monitor the child’s
tolerance for the grieving process and respect the child’s need to take breaks by focusing
on other themes, sometimes for weeks at a time. A single-minded therapeutic focus on
grief and trauma work can convert the therapy into a traumatic reminder and have a
iatrogenic impact on the child. As an adjunct to the goal of facilitating grieving, the
clinician needs to cultivate the surviving parent’s empathy, support, and capacity to
tolerate the child’s mourning.
2. Child’s ability to process the circumstances of the death. Children respond
with intense distress to reminders of trauma and loss. The careful identification of these
reminders helps the child to gain control over his feelings, and relieve fears that intense
affect will continue to accelerate to the point of causing damage (Pynoos et al., 1999). In
this process, the therapist can give meaning to seemingly random behaviors and thoughts
by interpreting them as an expression of the child’s preoccupation with the parent’s
death.
3. Problem solving and conflict resolution. The problems and conflicts
encountered by the child as the result of the death vary with the child’s developmental
stage. For toddlers, help in modulating their uncontrolled affect and outbursts of anger
and aggression is a key component of problem solving and conflict resolution.
Preschoolers encounter more complex social dilemmas, including how to talk to their
peers about the parent’s death and how to respond when other children and adults,
including new friends, ask about the parent. Practicing ways of responding to these
difficult social situations gives the child the tools for the internal work of mourning as
well.
4. Adjusting to changes in everyday life. The parent’s death invariably introduces
major changes in the young child’s daily routine, and these changes are often the source
of major distress because they serve as reminders of “how nothing is right anymore”
since the parent died. Facilitating the child’s adjustment to these changes through
practical interventions and allowing expression of feeling allows the work of mourning to
unfold with fewer obstacles.
5. Integrating the parent who died into the child’s ongoing sense of self. This goal
involves enabling the child to recall specific moments and situations that involved the
parent who died; encouraging the child and the surviving parent to talk to each other
about this parent; and giving them room to express sadness about the parent’s death to
each other.
6. Helping the child’s caregiver create a safe, stable and supportive environment.
This involves helping to identify reliable substitute attachment figures, develop consistent
care giving routines, and provide reassuring reminders of the dead parent.
7. Supporting the child’s emotional connections with a new attachment figure.
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This process involves helping the child accept the feelings of love for the new caregiver
as a natural extension of the child’s love for the parent who died.
CONDUCTING THE TREATMENT
Formation of the therapeutic relationship
The first step in conducting the treatment is to explain to the child the reason for
it. Talking candidly about the parent’s death and the difficult time that the child is going
through is almost always met by the child with relief that his predicament is being
recognized and addressed. When the child was present during the parent’s death, the
clinician should refer to this fact in a way that gives the child permission to express what
he witnessed.
Example. The therapist, making a first home visit to Josette, a 3-year-old girl who
had lost her mother, explained her presence as follows: “I am coming to play with you,
Josette, because Grammy told me that lots of things make you afraid since your mother
died. You are afraid at nighttime when you are sleeping and in the day when you are
awake. We’re gonna help you so that you don’t feel so scared all the time”. Josette
watched the therapist carefully as she spoke. She then turn to play a scene with a mother
and a baby animal that exemplified the child’s memories of times spent with her mother.
A child who is in the midst of grief may be hesitant to attach readily to a new
therapist. Young children have difficulty comprehending the finality of death and may
still be actively searching for their lost parent and engaging in the fantasy that the lost
parent will return. They may unconsciously view aligning with the therapist or loving a
new attachment figure as acts of disloyalty toward the lost parent, or as abandoning the
belief that the parent will return. Gradually, as the child is able to lessen his emotional
investment in the wish that the missing parent will return, the child will seek out new
relationships. The therapist needs to be patient in gaining the child’s trust. Trying to hurry
the process of mourning may lead to a hardening and consolidation of the child’s
defenses and to avoidance and resistance towards the therapeutic process.
Even after the child has formed an alliance with the therapist, he may feel
ambivalent about the relationship. Although meetings with the therapist may give him
relief from his distress, they will also remind the child of his loss. Therapists should be
prepared to tolerate this ambivalence and to allow the child to move at his own pace as
the treatment progresses.
Example. Jessica, at age 3, witnessed the violent death of her mother and suffered
the tragic loss of her father only a few days later. She used treatment sessions to act out
what she had witnessed in excruciating detail. These sessions were in sharp contrast to
her behavior outside the sessions, when she spoke of missing her parents but did not play
out any of the events she had witnessed. Although she used the sessions well to deal with
her painful feelings and memories, she had an ambivalent stance toward them evidenced
by her usual mode of greeting the therapist: first running down the stairs full of
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exuberance to greet her but then stopping abruptly and darting away, sometimes hiding
from the therapist and other times playing with toys. The therapist accepted the child’s
avoidant behavior, sometimes converting it into a “hide and seek” game, other times
joining the child in the activity at hand, or commenting in an understanding manner that
the child was not sure about wanting to see her at that particular time. These interventions
were sufficient to restore the child’s willingness to participate in the session.
What and how to tell the child about the parent’s death
If surviving parents seek consultation immediately after a parent has died, the
therapist may be asked to help tell the child about her parent’s death. Even if the child has
already been told about the death when the therapist enters the picture, it will be
necessary to repeat the truth about the parent’s death many times, both in and out of
treatment. There are three essential messages that must be conveyed to the child:
1) the parent can’t be with the child anymore; 2) the parent did not want to leave the
child; and 3) the parent will never come back. A fourth element needs to be introduced
when the child believes he made the parent go away. In this event, the therapist needs to
empathetically reassure the child that he had no role in the parent’s death. Each of these
essential messages is described more fully below.
1. Explaining that the parent cannot be with the child any more. All children,
including pre-verbal children, need to be given as soon as possible a clear explanation
about the parent’s death that will support the child’s reality testing. Children are keen
observers of adult behavior. They use is as a social reference that guides their own
emotional responses and behavior. In particular, young children are acutely aware of the
presence and absence of their parents. The absence of the dead parent and the distraught
behavior of family members are instant clues for the child that something bad has
happened. Delaying an explanation of the parent’s absence only serves to prolong the
child’s uncertainty and promote denial.
If the child comes to treatment without having been told of the parent’s death, the
first priority is to plan what and how to tell the child, engaging the surviving parent or
caregiver in this process. If the therapist will be involved in the telling, it is important that
the caregiver be present as well. This joint presence of caregiver and clinician underlines
that treatment involves a collaboration on behalf of the child. When the child already
knows about the parent’s death, the reason for treatment can be framed as help with the
child’s sad and angry feelings about the death.
The language used must be tailored to the child’s own abilities to understand and
use language. Therapists need to remember that children’s receptive language develops
more quickly than their expressive language, and that children understand more than they
are able to articulate. Even when the words are not completely understood, very young
babies and children register accurately the emotional tone associated with adults’ words,
using this emotional tone as an additional source of information that gives context to the
words.
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In speaking to babies who have not yet acquired language, it is important to use
small words and short sentences. Very young children will not understand information
about the way in which their parent died. That detailed information can be left out of the
message until the child indicates a readiness to hear it.
When speaking to a child aged 9–12 months, one can simply say, in a sincerely
sad tone, “Mommy died. She is gone and she can’t come back.” This should be followed
with immediate reassuring information about who will take care of the child.
A slightly older child, aged 15–18 months, might be offered a little more
information: “Mommy got very sick and she died. She can’t be with us any more.” As
with younger children, it is essential to tell toddlers who will take care of them and that
they will be safe.
Older children, who have acquired more mature expressive language, can be
helped to prepare emotionally for the bad news by using a cautionary statement such as
“We have something very sad to tell you”. This can be followed by the actual
information: “Your daddy/mommy can’t be with you (us) any more. He got very sick and
he died.” This initial message should always be followed with the reassurance that there
are still people who love the child and will take care of the child.
Children process information in small units at a time. The child needs to be given
time to respond at her own pace and in her own particular style, without having to receive
more information than she is ready for. Young children often respond to the news of the
parent’s death by playing out a theme related to wishes to reunite with the parent or to
fears about what will happen next, rather than with a direct question or other verbal
response. The therapist needs to be ready to follow up on these indirect responses, trying
to keep a stance that allows the child some distance without colluding with responses that
might signal excessive denial, dissociation, isolation of affect, or other rigid defensive
processes.
Example. Sam, aged two, listened seriously while his grandmother and therapist
told him about his mother’s death. He then went to his room and retrieved his favorite
bedtime stories. “Mommy read,” he said with assurance, and put the books on the floor
next to him. The therapist said, “These are wonderful stories. Your mommy loved to
read them to you. She loved you and it made her happy to take care of you.” After a
pause, the therapist picked up one of the books and handed it to Sam’s grandmother. She
said, “Your mommy is gone now, Sam. She can’t read to you any more. But your
grandma is here and she loves you. She will read your stories to you.” Sam’s
grandmother reached out, picked him up, and rocked him.
2. Explaining that the parent did not want to die. This essential but often
overlooked piece of information can also be conveyed using simple words and brief
sentences. The initial message to the child should focus on the fact that the parent did not
want to leave. “Your daddy did not want to die. He did not want to leave you. He loved
you very much. He wanted to be with you.”
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This explanation is not accurate if the parent made a conscious decision to die by
committing suicide. This raises the question of what to tell about a toddler or preschooler
about a parent’s suicide. The surviving parent may insist on waiting until the child is
older before offering such an overwhelming piece of information. Furman (1974, p. 105)
offers an example of a little boy, Mark, whose father died from an overdose of pills and
whose mother asked: “How can I tell Mark that his father loved us when he left us so
helpless and uncared for?” This mother was greatly helped by the explanation that her
husband suffered from a “special sickness of the mind”, which had not been evident in
time to help him with psychiatric treatment. The mother was then able to convey this
information to Mark, and in the process she realized that the child had picked up many
clues that his father had killed himself that were very upsetting for him. His mother’s
ability to speak with him allowed him to reveal fears and worries that had remained
unspoken until then.
3. Explaining that the parent can never come back. The third essential component
in talking to young children about death is telling them that the parent will not come
back. Telling a child that the parent will not return runs counter to the customary way of
reassuring a child suffering from separation anxiety, who needs to be told and shown
repeatedly that the parent will come back. For precisely this reason, stressing the finality
of death is pivotal in young children’s understanding of the difference between death and
a temporary separation. Providing this explanation can be a challenge both for the
therapist and for the surviving parent because it needs repeating again and again to
counter the child’s wishful expectations for an eventual reunion.
Example. Danny, aged 3, ostensibly knew that his father had died and would not
come back but said, as in passing: “I will show my daddy my picture”. The parent and the
therapist felt sorely tempted to agree, or at least to let this statement pass without
addressing it. Contradicting the child felt like an unnecessary cruelty. Yet this situation
needed to be understood as the child’s ongoing reality testing about the finality of death
in the face of an urgent wish to deny this finality. Therapist and parent supported the
child’s wish while affirming its impossibility. The therapist said: “I know how much you
want your daddy to see your picture.” The mother echoed this statement, saying sadly: “I
remember how much your daddy liked to see your pictures.” Once this wish was
accepted as understandable and legitimate, the therapist was able to remind Danny that it
was unattainable by saying: “It is so sad that he cannot see it because he died”. By
juxtaposing both realities, the therapist and the mother were lovingly teaching the child
that wishes cannot undo the facts.
4. Explaining that the child did not make the parent die. Young children have an
egocentric view of the world and often believe that they have caused the events that
affect them. For this reason, some children may need to be reassured frequently that they
did not make their beloved parent die. Sometimes children who have lost a parent act out
provocatively, as if testing to see how much the surviving parent can take before he or
she, too, goes away forever. The child should be told, both by the therapist and the
surviving parent, “You did not make your daddy die. Your mommy will not die or go
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away from you even if you make her angry. She loves you, and she will stay and take
care of you.” Opportunities to make this point also arise at times of separation from the
therapist, including at the ends of sessions when the child has expressed overwhelming
feelings.
It is important to carefully assess the individual child’s understanding of the
parent’s death and his role in it before offering reassurance. Some children do not harbor
the fantasy that they made the parent go away. For these children, reassuring them about
something that they did not worry about in the first place can raise unnecessary doubts
about their role as causal agents.
Example. Sam, at 3, had a very difficult session with the therapist. He wanted to
play hide-and-seek, but when the therapist hid he dissolved into tears and raged at her for
going away. Even after they moved to another game, Sam was angry. He threw toys and
books, and refused to help clean up. At the end of the session, as the therapist packed her
bag to leave, Sam bolted out the door and ran down the sidewalk. The therapist went to
him and caught him. He looked at her crying and said, “You are not my friend.” The
therapist held Sam and said, “I am your friend. You are very mad at me for hiding, and
very mad at me for leaving, but I am your friend and I will be back. Your mad feelings
didn’t make your mommy go away and they won’t make me go away either. I will say
goodbye now, but I’ll be back next week.” Together, Sam and the therapist found a
calendar, counted the number of “sleeps” until the therapist would return, and marked the
day of the next session.
Explaining the idea of death to a child
Death is difficult to define, and people often search for analogies such as “going
to sleep forever” or “going far, far away”. Generally, such analogies are not helpful.
Young children, who think concretely, take such explanations literally. They may
develop fears of going to sleep, or believe that everyone who goes away will never
return.
It is preferable to give the child a simple explanation of what happened to the
parent (a serious illness or a severe injury) and to say that the consequence of that illness
or injury is that the parent died and cannot come back. The explanation that the parent
cannot move anymore because he or she died is helpful because young children are very
interested in locomotion, and running, climbing, and jumping are central to their
everyday experience of themselves. In addition, they can easily test the fact that they
have not died by moving an arm or a leg even when they are lying down and falling
asleep.
One recurrent dilemma in choosing words to explain the death is that the same
words are used for daily occurrences and for the causes of death. “Being sick”, for
example, runs the whole gamut from the common cold to a fatal illness. Every effort
should be made to help the child differentiate between everyday illnesses and the kind of
illness that killed the parent and between everyday accidents and fatal ones. The failure to
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do so entails the risk that the child will constantly draw connections between everyday
experiences and the parent’s death.
It is considerably easier for young children to grasp the death of a parent if they
have already acquired a concept of death. In the course of development, questions about
death and dying usually emerge at about age 4, although the range may vary depending
on external circumstances and the child’s developmental level. Even before children are
old enough to ask about death and dying, they may have encountered death. A very
young child may have lost a pet, or seen a dead bird or other animal when out for a walk.
For toddlers who have never encountered a dead animal and are too young to have asked
about death as a concept, the information that the parent died needs to be very simple and
concrete: “Mommy got very sick and now she can’t move any more. She can’t hold you
or play with you. She can’t be with us any more” or, if the death was caused by an
accident: “Daddy got hurt and was broken so much that the doctor could not fix him”.
The link with the concept of dying can be built on the basis of these explanations: “She
can’t come because she is dead”. For older preschoolers, who ask about death as part of
their normal development, the explanations can be geared to what they already know. For
both toddlers and preschoolers, it is helpful to look for examples in the natural world, and
this can be worked into the treatment.
Example. One child who had lost his mother in an automobile accident first
talked about the permanence of death when he saw a dead beetle in the park. He said, “It
can’t move any more. Not ever. It won’t turn over.” The therapist was able to draw a
parallel to his mother and say, “Not ever. Like your mommy can’t come back.”
Example. A couple of months after Jason, age 4, learned of the death of his
mother he stated to the therapist, “I saw a snake eaten by a crocodile on the TV.” Jason
added that “the snake was dead forever.” When the therapist asked Jason what happens
to snakes when they die, Jason (who was afraid of snakes) replied “snakes don’t go to
heaven because Jesus doesn’t like snakes.” Jason went on to say that there were “nice
lions, tigers and penguins in heaven.” The therapist commented to Jason that these
animals were all watching over his mommy and keeping her safe.
In general, explanations about the parent’s death need to be guided by the child’s
questions. After providing the basic information that the parent died, did not want to
leave the child, and cannot come back, the adult should wait for the child to take the lead
in indicating what additional information she needs. Some common questions are, What
do daddies do in heaven? Why did mommy leave without saying goodbye? What the child
asks gives an indication of what the child is able to conceptualize and tolerate. An
attitude of willingness to answer questions and to speak about the dead parent will give
the child permission to express what she needs to know at her own pace. There needs to
be a balance between neither forcing nor avoiding the subject. Sometimes the child ‘s
questions emerge months after the initial information about the parent’s death.
Example. Gilliam, 30 months old, was enacting the car crash in which his father
died three months after the first therapy session. He said: “My dad comes to see me
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sometimes”. The therapist replied: “That is very nice. You miss you daddy very much
and it is so good that you can see him sometimes”. Gilliam then asked why his father
went away. The therapist told him that he didn’t go away, he died and could not come
back. Gilliam asked what “died” meant. The therapist explained that his dad fell from the
car and got very hurt, so hurt that the doctors could not make him better. Gilliam listened
intently to this explanation. This exchange occurred two months after Gilliam had
spontaneously said that his father died for the first time, and illustrates the drawn-out
process of understanding this difficult concept.
Beliefs about life after death, going to heaven, and being in God’s presence vary
from family to family depending on their religious affiliations and degrees of observance.
It is important to learn about the family beliefs and practices and how these are taught to
the child in order to frame explanations about the parent’s death that are consistent with
what the adults believe and what the child hears at home.
When the treatment involves joint child-parent sessions, the therapist can let the
parent or caregiver answer the child’s questions. The rituals and myths that families
create about death and dying are precious traditions that need to be respected and
nurtured.
Example. A grandmother told her 3-year-old granddaughter that her mother had
died and was in heaven. The little girl turned to the therapist and asked: “What is
heaven?” The therapist replied: “Your granny will tell you”. The grandmother thought for
a minute and then answered: “Heaven is the air we breathe. The air around us smells
sweeter because your momma is in it”. Another grandmother explained to her 30-month
grandson that his mother came to visit him in the butterflies that came to their garden,
which the grandmother had planted with flowers that specifically attracted butterflies.
This garden became a place of solace for this child and his grandmother.
Giving meaning to the parent’s death: offering an answer to “why”?
Three, four and five year olds routinely ask “why” in their all-absorbing effort to
find out how the world works. “Why is the sky blue? Why is the moon following us?
Why is that lady crying? Why can’t I go with you?” All parents are familiar with
children’s earnest desire for answers to these and thousands of other questions. Baffling
and even annoying as they may be, these questions are priceless expressions of young
children’s search for meaning and for their trust that their parents have the answer to
everything there is to know.
Nowhere is the need to know the reason “why” more urgent than when the child
is deprived of something precious, and nothing is more precious to the child than a
beloved parent. Preschoolers may ask explicitly why the parent died, but they may also
keep the question to themselves if they are scared of the adults’ response. Offering an
explanation when the child is able to understand it can be a source of comfort and
reassurance if done in a way that supports the child’s need to think well of the dead
parent.
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Children respond best to story telling because telling a story embodies the human
propensity to find meaning in events. When the explanation for the parent’s death can be
given in the form of a story, it often becomes part of a family lore inherited by the child
from the loving adults. Parents may die while fulfilling their duties or in the course of an
effort to help others, as in the case of soldiers, policemen, firemen, Good Samaritans, and
many others. The story of how they died may be a source of admiration and pride
intermingled with sorrow, and telling the child how it happened may become a source of
inspiration and idealism that sustains the child.
In providing such an explanation, adults need to be careful to preserve the child’s
need to experience the full range of feelings associated with grief and mourning. Children
whose parents die as heroes may feel compelled to glorify the death, suppressing
feelings of grief which may emerge in distorted ways through attempts to emulate the
dead parent by engaging in dangerous behavior.
Example. Gregg, age 4, lost his father during a fire. His father was a firefighter
who was overcome with smoke when he tried to rescue four people trapped in a burning
apartment. Gregg’s grandfather told his grandson that the father had died trying to save
people from being burned. Gregg asked many questions. “Why was there a fire? Why
didn’t the people run? Why couldn’t daddy run away?” The grandfather tried valiantly to
answer the child’s questions, sometimes saying “I don’t know” when he was overcome
by the lack of answers. Gregg attended his father’s funeral, and witnessed the many
tributes to his father’s heroism. A few weeks later, his mother overheard Gregg telling
another 4-year-old: “My daddy died because he is a hero”. He had equated being a hero
with dying, and his mother felt compelled to tell him later: “Your daddy is a hero, but
sometimes heroes don’t die. Your daddy died because the fire was too hot and there was
too much smoke and he could not breathe”. Gregg mulled over this explanation for a long
time, and became very interested in issues of breathing, fire, and smoke. He was also
heard saying to himself, while playing with his action figures: “Sometimes heroes don’t
die”. This example illustrates the long process of making meaning out of a parent’s death
as the child acquires increasing knowledge and applies it to update his understanding of
reality.
Parents may die as the result of an accident. Children may then want to know why
the accident happened, and ask questions about every detail of it. The motivation for
these questions is often the child’s fear that the parent did something wrong, or the
child’s fear that a similar accident may happen to him or her as well. In such
circumstances, it is best to give the child an explanation that protects the child’s need to
think well of the parent and reassures the child of his or her own safety.
Example. The mother of Diana, age 5, was killed in a car accident while driving at
a high speed. Diana overheard people speaking about these facts, and asked: “Did
mommy drive too fast?” Her aunt told her: “I think she did not mean to drive too fast. I
think she made a mistake.” In the following months, Diana asked anxiously before
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getting into a car: “Will you drive too fast?” Her aunt unfailingly replied: “No, I won’t. I
will make sure we are safe”.
Parents may also die following an illness, which may be short or prolonged.
Telling the child the name of the illness and explaining that it is very rare can be a useful
way of containing the child’s fear of death whenever a common childhood illness occurs.
Sometimes children equate being ill with being bad because parents, in the course of their
illness, may become irritable, withdrawn, engage in behavior that is scary to the child, or
look frightening due to the effects of the illness or the side effects of the treatment.
Children can get relief from an explanation that, for example, the parent did not want to
be scary but was not feeling well, and that the doctor could not make the parent feel
better. Narratives that the parent died in spite of efforts to prevent it can give a frame of
meaning that enables the child to learn that sometimes things happen that are inevitable in
spite of one’s best efforts.
What not to tell a child is just as important as what to tell. Adults sometimes think
that the child needs to be told every detail of the parent’s death because “the child will
find out sooner or later anyway”. While it is true that adults often speak about grisly
aspects of the parent’s death without realizing that the child is paying attention, this is not
an excuse to burden the child with emotionally unmanageable facts. The example below
illustrates how complex these decisions can be.
Example. Sandra, age 3, lost her mother and her father when the father stabbed
the mother to death and then shot himself. Sandra was staying overnight with her
grandparents at the time of the killings. Sandra’s uncle wanted to tell Sandra the exact
circumstances of the deaths. Sandra’s grandparents wanted to tell her only that her
mother and her father had died. The clinician proposed following the grandparents’
wishes, and explained to the uncle that this knowledge alone would be so difficult for
Sandra that adding the additional information would be emotionally overwhelming for
her. Persuading the uncle took the bulk of three sessions, but it was time well spent
because it was essential to obtain his agreement to prevent his telling Sandra about the
murder-suicide when he was alone with the child. Several months after being told of the
deaths, Sandra asked the uncle why her parents had died. He replied: “They got hurt
really bad”. This information satisfied Sandra for many months. Later, she asked how
they got hurt, and she was told that the mother got cut with a knife and the father got hurt
with a gun, but there was no mention of the murder-suicide and Sandra did not ask the
crucial question: “Who did it?” The family agreed that they would wait until Sandra was
older to tell her this nearly ungraspable piece of information.
Addressing Children’s Fears
Bereaved infants, toddlers and preschoolers must confront many fearful
possibilities, and they may express their fears either non-verbally or through direct
questions. Some common worries are described below.
“Will other people I love leave me?”
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Inevitably, a child whose parent has died will fear that his surviving parent will
leave him, too. Adults are often reluctant to reassure the child because their own trust that
they will survive to raise the child to adulthood has been shaken. Adults sometimes
rationalize their failure to offer this reassurance by saying that they don’t know for sure
whether they will live a long time and they don’t want to lie to the child. With the
therapist’s help, caregivers are usually able to understand the importance of overcoming
their own fear of dying in order to reassure the child. They can say, for example: “I will
not die for a long time because I am healthy and strong. What happened to mommy
doesn’t happen very much”.
“Will I die also?”
Much as they need to be reassured that their surviving parent will not die, children
need to be told in no uncertain terms that they will not die either. Again, the explanation
that what happened to the dead parent is very unusual and does not happen very much is
helpful in this process. The child can be told that he is healthy, strong, and that the
surviving parent will take good care of him.
Example. Calvin, age 4, talked with his therapist about his worries that he was
going to heaven and wanted to be sure that he could take the stuffed dog with whom he
slept every night and his favorite toys. The therapist replied to Calvin, “You are not going
to be going to heaven for a very long time. First you are going to grow up and be a big
boy and go to more baseball games and have more trips to the zoo and the park. Then
eventually you will become a man and do lots of things in life before you go to heaven.”
The therapist then explained to Calvin that his mother was very sick and too ill to go on
living and that was why she died.
“Who will take care of me?”
An immediate question in children’s mind tends to be: “What will happen to me?”
Children need to know who will take care of them because predictability is equated with
safety, and safety is paramount in their minds. The more specific the parent or caregiver
can be in describing to the child what the daily routine will be like, the better the child
can focus on mourning the parent’s without compounding the grief with worry about the
self. If plans for the care of the child are uncertain, the child can be told about what will
happen immediately, introducing as much predictability as possible. Statements such as
“I am reading you a book just like your mommy did” or “I’m going to give you a bath
just like your daddy used to” can offer reassurance that they are being cared for by
drawing associations with their initial caregivers.
Sometimes children ask: “Who will be my (mommy or daddy) now?” When there
is no clear parental substitute available and the child’s question does not have a ready
answer (i.e., “your grandpa loves you the way your daddy loved you, and he will help
take care of you”), the parent is often confronted with his or her own uncertainty about
either wanting or being able to find a new partner. This uncertainty may be accompanied
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by guilt about not providing a substitute parent for the child. Questions such as this can
be addressed by speaking to the child’s feelings of wish for things to be the same again
and worry about what will happen: “I know you really want a daddy. Maybe you will
have a new daddy someday. In the meantime, I will take good care of you”. The therapist
can help parents as they grope for answers by pointing out that the child’s questions are
often indirect expressions of a wish or a worry. The concrete answer is less important
than the willingness to think along with the child about what might be prompting the
question.
For children who have lost both parents, it will take time for them to grieve and
then transition into accepting a new caregiver, especially if this relationship is totally
new. Forced attachment can feel like yet another violation.
Example. A 5-year-old child who, in a moment of despair, cried out “I want my
mommy” was told by her maternal aunt who had only met the child 2 weeks previously,
“I am your mommy.” This did not serve to comfort the child and instead created a great
deal of confusion and anguish. This response was in such stark contrast to her emotional
experience that it sent her into despair and made her feel even more alone.
Example. Jeremy, at age 3, longed for the return of his parents for months. During
this time he switched back and forth between calling his grandmother “nana” and
“mama.” In a play session six months into treatment, Jeremy placed the family of dolls in
the car which included his mother and father and said about the grandmother “She’s in
charge now.” He was able to go at his own pace, gradually transitioning to accepting his
grandmother as his new mama.
“Did I cause the death?”
Sometimes the child asks about dying soon after an outburst of anger or a fight
with the surviving parent. In these situations, it is useful to address the child’s underlying
fear that anger can kill: “Even when you are angry with me and I am angry with you, we
can’t get hurt and die.” Signs that a child feels responsible for her parent’s death can be
as direct as a child’s statement that, “Daddy went away because I was a bad girl.”
Children need ongoing help in learning about causality by differentiating between their
fantasies and objective reality.
“I want to die so I can be with mommy.”
In their anguish, children often think that dying will allow them to be with the
dead parent. Emphasizing the loss of relationships with living people whom the child
loves and the loss of pleasurable activities can help restore some balance by reminding
the child of the pleasures of being alive.
Example. Alexander, age 4, was very distraught following the death of his father.
He stated to his mother, “I want to die, mommy.” Alexander had some very specific ideas
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about how he would do this that required immediate intervention. He talked about
wanting to get hit by a car or drown in the bathtub. The therapist asked Alexander if he
knew what happened after someone dies and Alexander replied that they go to heaven.
The therapist then stated to Alexander, “If you die you will not be able to see your
mommy, me or your friends at school and we would all miss you very much.” As
Alexander was able to express his grief over the loss of his father, he no longer expressed
a desire to die.
Example. Jonathan, age 4, awoke in the middle of the night screaming, “God the
father, take me because my father is gone from me.” This child’s urgent wish to reunite
with a father figure through death is a compelling example of the despair children can
feel about losing the parent. His mother said: “I am not gone from you. I want you to stay
with me because I love you so much”.
Consolidating positive and negative feelings about the lost parent
Toddlers and preschoolers struggle with the difficult task of developing object
constancy, which involves learning that they continue to love somebody even when they
are angry with that person. For children who lost a parent to death, this is a particularly
difficult challenge because they fear that their anger may have caused the parent’s death.
Ambivalence can be a dangerous state of mind when it is perceived as having the power
to hurt or kill. The following vignette, taken from the therapist’s process notes, illustrates
how the therapist helped 28-month old Gilliam understand that different feelings can
happen at the same time.
Example. “Gilliam showed me the toy bus with passengers on the seats. He
pointed to a woman passenger and said: ‘She is sad’ despite the fact that the woman had a
smile on her face. He played with different toys but kept going back to the woman,
saying each time that she was sad. On the third time, I said that the lady had been sad for
a long time. Gilliam replied: ‘Gilliam sad long time’. I told Gilliam that he had been sad
for a long time and so was his mamma and his sister Marissa. I then said that they would
not be sad forever and that he and his mom and his sister would be happy again. I said
that it is so sad his daddy is gone and it takes a while to be happy again. After a few
minutes of sitting quietly on the floor next to me, he got up and squeezed his favorite
stuffed animal very hard. He shook for several moments as he clenched his teeth and
made a grimace. I told Gilliam that he is not only sad that his dad died, he is also angry. I
told him his dad did not want to die and leave him, but it still makes Gilliam mad that he
did. He then came back to join me on the floor and got out the dishes. For the first time,
he played at sharing something with me. He pretended to put food on our plates and then
pretended to drink out of his cup before placing it to my lips to share his juice with me.
We went back and forth in this reciprocal play for several minutes. Them Gilliam moved
around to my back and leaned his body next to mine. Eventually he placed his arms
around me, hugging me for several moments. I stayed quiet, not wanting to scare him out
of this moment of connection. He then picked up a book and we looked at it together”.
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This complex sequence illustrates this toddler’s capacity to get relief from the
therapist’s explanation that he could be sad and angry at the same time and that he would
be happy again. Particularly noteworthy is that this explanation allowed Gilliam to
engage in a close emotional encounter with the therapist, establishing physical contact
with her and sharing food with her for the first time.
Children’s negative behavior towards another person can be transformed by
putting the feelings of the other into words. Articulating for the child how people or
animals might be feeling focuses on the child’s capacity for intersubjectivity,
encouraging empathy for the experience of others. The example below is an illustration
of this form of intervention.
Modeling manageable separation: therapist’s vacation and treatment termination
The treatment routinely presents opportunities to model and practice how to make
separations emotionally manageable by allowing the child a measure of control.
Whenever possible, the therapist needs to allot ample time to the discussion of impending
separations or scheduling changes, and to be alert to overt and covert manifestations of
the child’s fear of loss, fear of abandonment, and anger at the therapist. Children are often
relieved when the therapist speaks candidly about the child’s fear that the therapist will
die while away, just as the parent died. This topic can be brought up again after the
therapist’s return. One example involves a 3-year-old who steadily refused to look at his
therapist after she came back from vacation, and only established eye contact when she
said: “See, I came back, just as I promised you I would”.
Separations have a special meaning for children who lost a parent, and the
therapist must devote attention to preparing the child for vacations. In addition to talking
about vacations in advance, the therapist will want to offer concrete evidence of her
continued existence during her absence, and concrete reassurance that she will return.
Postcards sent during the vacation, photographs of the therapist for the child to keep
during the vacation, and a calendar with special dates marked, including the day on which
the therapist will return, are all tools that can help make the separation manageable for
the child. The child may also need reassurance that the therapist will remember him
during the absence, and a picture of the child that the therapist can keep while being away
may be helpful. Children who have lost a parent need to know both that the therapist will
continue to exist and that the child will continue to exist in the therapist’s mind during the
absence.
No matter how carefully she has prepared the child for her absence, the therapist
must be equally prepared to help the child express and process feelings of anger and fear
about the absence. These feelings may surface before the therapist leaves, or after she
returns.
Example. Gilliam, age 3, expressed in his play just how angry he was at his
therapist when they were not able to meet for two weeks due to a holiday and then illness.
Gilliam took the doll that most resembled the therapist and hid her under a pillow for a
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long time. Later he took the doll he had chosen to represent himself and went in search of
the lost woman. Gilliam exclaimed as he lifted the pillow “lady died.” He then took the
Gilliam doll and hit her repeatedly. The therapist stated that she was gone way too long
and it made Gilliam really angry because he was worried that she was dead and might not
return.
Example. Gilliam’s mother commented that she had been crying that morning
and that Gilliam noticed it. She told Gilliam that she was missing his dad and Gilliam
stated that he missed him too. The therapist then went to join Gilliam, who was in the
back yard stamping on ants. The therapist commented that the ants wanted to live, and
told him that they died and could no longer move after he crushed them. Gilliam stopped.
He then initiated various hide-and-seek games, ranging from hiding himself so the
therapist could find him to hiding the girl doll and having us search for her. The therapist
commented that she had been gone for a while on vacation but she did come back, just as
she said she would. He nodded.
Termination of treatment is another loss for the child and needs to be planned and
anticipated far in advance to give the child adequate time to process it. A gradual
reduction in the frequency of sessions, follow-up telephone contact, birthday or holiday
cards and sessions scheduled as needed, stress the continuing existence of the therapist
and the fact that the child continues to exist in the therapist’s mind. These steps also help
the child understand that he can continue to think about the therapist and the things that
they did together even after the therapy has ended. The process of saying goodbye to, but
continuing to think about, the therapist is a poignant way for the child to process the fact
that he continues to think about, and treasure, the lost parent even though the parent has
died.
For this reason, the process of termination with a bereaved child should include
the joint creation, during therapy sessions, of concrete reminders of the therapy that the
child can keep. Just as the child and his caregivers may have created a scrapbook or
memory book to help the child hold onto the image of the lost parent, the child and the
therapist can create together a memory book that will help the child hold onto the image
of the therapist and the treatment. The contents of such a book will vary for each child
but should, at a minimum, include a picture of the child and therapist together in the
setting in which the treatment was conducted.
Example. Elizabeth, age 4, was placed in foster care after her mother’s death. She
had worked with her therapist for only a few weeks when the therapist learned that the
family had arranged for Elizabeth to go to another state to live with her grandmother.
Her grandmother would become her permanent caregiver. The therapist had only three
weeks to prepare Elizabeth for the termination before her grandmother was scheduled to
arrive. In the first week, the therapist brought a calendar and a map to the session. She
told Elizabeth that her grandmother was coming for her and that she was going to live
with her grandmother, who would love her and take care of her. She showed Elizabeth
the map and marked the town where they were and the town that Elizabeth would be
going to. She pointed to other towns on the map, places where Elizabeth’s relatives lived,
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and said, “Here is where you will go to live with your grandma. I will still be here. Your
uncle lives in this town, and your other grandma lives in this town. You can’t see your
uncle, but you know he is there and he loves you. You won’t see me any more, but I will
still be here, and I will still love you and think about you.” Elizabeth asked, “Where is my
mommy on the map?” The therapist said, “Heaven isn’t on this map. There are lots of
places that aren’t on this map. But your mommy is in heaven and she is still in your heart.
You still think about her, and she loves you. She wants to be here with you, even if you
can’t see her.” Then the therapist brought out the calendar. She marked the current date
and the date of their last time together on the calendar, and together she and Elizabeth put
stickers on special dates: the last day of preschool, the day her grandmother would come,
the day that they would move. Elizabeth kept the calendar and every night before
bedtime, she marked off the day that had just ended.
In the next session, Elizabeth and the therapist made a little book together. They
pasted the map on one page, and Polaroid pictures on other pages. The therapist had
obtained a picture of Elizabeth’s grandmother from family members, and she pasted that
picture on the map. The therapist asked Elizabeth to remember things that they had done
together, and she wrote those things in the book. She said, “Do you remember when we
wrote a letter to your mommy?” Elizabeth said that she remembered. Elizabeth said,
“Write a letter to me for our book!” The therapist agreed to write a letter and then asked
Elizabeth, “Would you like to write a letter to me? I could write down your words and
put them in the book.” Elizabeth dictated her letter to the therapist. At the end of the
session, the therapist said that she would take all of the pages and fasten them together so
that Elizabeth would have the book to take with her and keep always. Elizabeth said,
“You need a book, too.” The therapist said, “You want me to remember you. I will
always remember you. But I will make a copy of the book for me to keep.”
The therapist brought the finished book, bound together with a ribbon, to the last
session. She brought her own photocopy of the book along to show Elizabeth. Elizabeth
said, “Yours isn’t pretty,” and looked as if she were about to cry. The therapist said,
“Maybe we could do something together to make it pretty.” Elizabeth brightened and
said, “We can color it!” She colored in some of the pages and drew flowers on the cover
for decorations. When she was finished the therapist said, “You wanted me to have
something pretty to remember you by, and you made me a beautiful book.” Before the
session ended, Elizabeth and the therapist made two cards together: one for Elizabeth to
mail to the therapist after she got to her new home, and one for the therapist to mail to
Elizabeth on her birthday. At the end of the session, the therapist said goodbye with
promises that she would miss Elizabeth, think of her every day, and look forward to
getting the card from her new home.
This termination process, though unfortunately brief, contained several essential
elements. It was planned and not sudden and unanticipated. It provided the child with
concrete ways to remember the therapist and the treatment. It provided the child with
proof that the therapist had reminders that would keep the child alive in the therapist’s
mind. Finally, it tied the loss of the therapist to the loss of the parent and made concrete
the proposition that an absent person can be real and alive in our hearts.
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THERAPEUTIC STRATEGIES AND TOOLS
Young children express their emotional experience primarily through play and
physical movement: Motion becomes the carrier of emotion. Observing what an infant,
toddler or preschooler does as she acts on and moves through the world is an essential
therapeutic tool because the child’s unique temperamental and personality characteristics
need to be incorporated in the intervention. A child who is shy and retiring needs a
different therapeutic tempo than a boisterous, energetic child; a child who loves to use
words can profit from different interventions than a child who prefers physical action or
one who spends long periods of time involved in quiet symbolic play. Older preschoolers
can be remarkably adept at using and understanding words to express their feelings, but
even these children use play and action as indispensable adjuncts to words. In order to
accommodate children of different temperament and at different levels of comfort with
symbolic play, the therapist working with young children should be prepared to work
flexibly, with a variety of the materials and strategies discussed below.
Choosing therapeutic toys
The therapeutic playroom should have a variety of age-appropriate toys to
accommodate a variety of avenues of expression. At the same time, the therapist should
be careful to not have so many toys that the child becomes too distracted and unable to
make use of any of them.
It is important to incorporate dolls that reflect the child’s family composition
before the parent’s death as well as toys that allow the child to re-enact the circumstances
of the death, such as a medical kit, an ambulance, helping figures (doctor, nurse,
firefighter, police officer) and in situations where violence was involved, a police car.
The family of dolls should reflect the racial composition of the child and the family
whenever possible and include dolls that represent extended family members or other key
caregivers. Wild and farm animals and their babies are very helpful when children need
to establish some emotional distance by staying away from the doll families; dinosaurs
are often used by children as representatives of the monsters of their imagination, which
include their most frightening thoughts. Superhero figures allow a child to play out
fantasies of rescue and protection. Puppets representing a variety of states of mind can
serve a similar function. Telephones foster communication between a child and their
missing parent or between the therapist and child when what being said is hard to say
more directly. Neutral toys, including kitchen utensils and building blocks, allow children
to engage in social play that promotes reciprocity and defuses anxiety, but they can also
serve a defensive function by engaging the child in conventional, monotonous play to
fend off emotion.
The therapist can have a flexible approach to the toys that are deployed in the
playroom, choosing different ones according to the child’s interest. However, it is
important to have always available the toys that the child singled out as emotionally
important. Even when they are not set up, they need to be easily retrievable to provide
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continuity to the therapeutic process. When the treatment occurs in the setting of the
home, it is optimal to have a toy bag that is brought reliably to each session with its
contents intact.
Example. Sonny, 2 years old, made clear how important it was for him to have
control over the toys that he needed. At the end of a home-based session in which he reenacted the car accident in which his mother died, he told the therapist: “Always have the
car here”. The next session he gave the car to the therapist and said: “I don’t want it
today”. Several weeks later, after not seeing the car, he told the therapist: “You can bring
the car back today”. This child was playing an active role in regulating the stimuli that he
could tolerate as reminders of the car accident and of his mother’s death.
Play
Play is children’s most eloquent medium for making sense of what happens to
them, managing their anxiety, and gaining a sense of mastery. As Erik Erikson (1950)
pointed out, children use play to set up model situations that reflect reality and allow
them to experiment with a variety of outcomes, including those they most fear and those
they most wish for. Through play, children can suspend the constraints of everyday life
and give free rein to their imaginations.
In the therapeutic setting, play becomes an opportunity for creating joint meaning
between the child and the adult. The therapist’s interventions are geared to
clarifying the child’s communications, giving words to underlying feelings, fears and
wishes, interpreting the symbolic meaning of the play, and helping the child to regulate
emotion when the play becomes disruptive or aggressive due to the breaking through of
unmanageable anxiety. When the parent is present in joint sessions, the therapist’s
interventions are also geared at helping the parent and child create a joint play experience
where the child’s feelings can be understood and supported.
With children who have not yet achieved or consolidated symbolic function, play
can be quite concrete but nevertheless very eloquent and amenable to therapeutic
intervention. Some examples are given below.
Example. Maria, 18 months, lost her mother to a drug overdose after months of
chaotic care and was placed in a foster home. Her language was limited to a few twoword sentences which included: “Where mama?” and “bye-bye”. In her play, she
repeatedly placed the baby doll in the crib and abruptly overturned the crib, making the
doll fall out. The therapist’s intervention consisted of saying quietly: “Mama went byebye and the baby fell”. Maria watched the therapist silently, retrieved the doll and
repeated the scene three more times. The therapist understood this sequence as Maria’s
expression of feeling displaced and out of balance, and needing reassurance. The
therapist then took the doll from the floor, cradled it in her arms saying “We’ll take care
of you, baby. Don’t be scared. You’ll be all right”, and then put it back in the crib. This
sequence was repeated three more times, until Maria spontaneously took over the
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reassuring outcome, picking up the doll from the floor and cradling it in her arms saying:
“baby, baby”.
In this play sequence, Maria was focused on her own wellbeing rather than on her
mother’s whereabouts. In another play sequence, she clearly showed that she missed her
mother. She hid the doll under a pillow and then played with other toys. Suddenly, she
said: “Where mama?” and looked all over for the doll without ever lifting the pillow, as if
forgetting where she had placed it although only five minutes had gone by. The therapist
said: “Mama is gone, and Maria is looking for her”. Maria became increasingly
distraught, looking everywhere except under the pillow. She ignored the therapist’s
suggestion to look under the pillow, and her whimpering became louder. The therapist
patted the pillow, and said: “Look here”. Maria lifted the pillow and hugged the doll,
saying: “Mama”. The therapist said: “You want so much to see your mama. It is so sad
that mama is gone bye-bye”. Maria placed the doll carefully next to her and started
playing with different toys.
These play sequences illustrate that the same toy can have different meanings for
the child at different times: in the first play sequence, the doll represents Maria, while in
the second sequence it represents her mother. Sometimes the meaning of the toy may be
ambiguous, or it may have several meanings at once, as shown in the following sequence.
Example. Maria, 20 months, was playing with a toy hammer, banging on wooden
cubes. The banging became progressively more driven. She then switched to banging on
the doll’s head. The therapist knew that Maria both witnessed domestic violence and was
routinely slapped as a form of punishment, and was unsure whether the doll represented
Maria’s re-enactment of being hit or her anger at her mother for dying and leaving her.
The therapist chose to watch quietly and to describe both Maria’s behavior and the doll’s
experience: “Maria is so angry. She is hitting the doll. The doll says: ‘Stop, stop, it hurts’.
The doll doesn’t like to be hit”. Maria continued hitting, becoming progressively more
frantic as she did so. The therapist recognized this progression as an interruption of play
by unmanageable anxiety, and said: “Maria, I am going to help you not be so angry. Let’s
be gentle” She put her hand over Maria’s hand and guided her hand to the wooden table,
saying: “This table needs fixing. Let’s bang the corner so it is really strong”.
Children who have some capacity for symbolic play may use it to convey themes
that are indirectly linked to the parent’s death. When the therapist broaches this subject,
the child may respond with play that conveys a wish to be reunited with the parent and
protected from frightening events, as shown in the example below.
Example. Josette, age 3, had just heard the therapist explain that she would be
coming to play because Josette was feeling sad and having many fears after her mother
died. She then turned to the animal toys that the therapist brought, putting a lion cub on
the back of a lioness and making them trot together. The therapist asked: “How is the
baby lion feeling riding on the mama’s back?” The child answered: “It’s fun”. The
therapist said: “The mama lion is very strong. She can carry the baby on her back without
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any worries, and the baby can just have fun”. Josette nodded and said: “Yeah, no
worries”. She then took a dinosaur and made it roar very close to the mother and baby
lion. The therapist said: “Now the worry is back because the dinosaur is scaring the
mama and the baby”. The child then instructed the therapist to take another dinosaur and
use it to protect the mother and baby lion, while her own dinosaur continued to scare
them with her roars.
This sequence illustrates the non-linear nature of children’s play and the way it is
used to convey salient emotional concerns that are not quickly resolved. In her play,
Josette was giving the therapist a synopsis of a time when she could be carefree in her
reliance on her mother, followed by a time of worry when she wished that mother and
child were protected by a powerful figure. Josette was not yet ready to play out the actual
loss of her mother and the grief that accompanied it. However, she needed the therapist to
recognize and amplify these themes, enabling her to long for the times of fun and safety
with her mother and to begin testing the therapist’s ability to protect her from danger and
fear.
The child’s play is an eloquent barometer of what the child is able to tolerate and
explore. The therapist needs to be careful about not becoming overly invested on a predefined treatment outcome where success is equated with the child’s completion of
mourning and moving on. Particularly when psychotherapy is time-limited due to
financial constraints or other factors, the therapist needs to be cognizant of the possibility
that the child’s mourning process will be incomplete by the time treatment must end.
Even when this is the case, the treatment can be greatly beneficial by providing the child
with the emotional and cognitive tools that will enable him to continue this process after
treatment ends. These tools include enhanced capacity to tolerate and regulate strong
emotion, to express feelings through words and symbolic play, and to rely on
interpersonal relationships to cope with fear and anxiety. In this sense, mourning for the
parent is “terminable and interminable”, a work in progress that will continue in different
manifestations throughout the child’s life.
Games
Some childhood games seem explicitly designed to help children cope with the
universal fears of separation and loss. There are versions of these games for the premobile baby and the toddler, and they can help pre-verbal and verbal children alike.
Peek-a-boo reassures babies that objects continue to exist even when they are
momentarily out of sight. Hide-and-seek gives the mobile child an active role in seeking
out and retrieving the lost person. Selma Fraiberg (1959) described the meaning of this
game as “repeating disappearance and return under conditions he controls.” Toys such as
the jack-in-the-box and busy boxes are useful adjuncts to these games for babies and preverbal toddlers.
Children who lost a parent often take the initiative in playing these games in a
spontaneous effort to give meaning to the parent’s absence and to make the loved one
reappear. When the adult initiates these games, the child receives the reassuring message
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that even though the dead parent will not come back, this absence is an exception to the
rule that people usually come back after they leave. Sometimes this theme is repeated
over many sessions, as in the example below from the therapist’s narrative notes of a
home visit.
Example. “Gilliam, 30 months old, began tossing people behind the couch. First it
was the fireman that went flying over my head. I asked Gilliam, “Does he come back?”
Gilliam replied with a gruff ‘no’. I stated that people usually come back. Gilliam said
angrily ‘no, they don’t”. I told Gilliam that sometimes people don’t come back, like his
mother who cannot come back because she died, but most people do come back. He left
the room to go to the bathroom and when he came back, I had retrieved the fireman from
behind the couch and had it in my hand. I said: ‘You see, people do get found and return
almost always’. At that moment, his sister came back from school, and I said: ‘Marissa
goes to school every day and comes back, and your dad goes to work but always comes
back’. Gabriel then engaged Marissa in some play”.
The session two weeks later repeated a similar theme, but Gilliam remembered
the therapist’s words from the earlier session. The therapist wrote in her narrative notes:
“Gilliam played a game where several times people get lost and then found. I commented
that every time someone got lost, they were found again. Gilliam told me: ‘Hardly ever
somebody doesn’t come back’. He repeated almost verbatim my words of two weeks
ago”. This session indicated Gilliam’s increased ability to differentiate between
separation and death.
Hide-and-seek games can be varied to give them renewed interest, for example by
hiding toys or by briefly introducing a hide-and-seek element into a different ongoing
game. Parents can orchestrate a hide-and-seek game among family members or among
peers. Children add their own creative elements as well.
Example. One resourceful 5-year-old suggested turning the lights off in the house
at dusk, before it was too dark, to add an element of adventure to the game. He and his 3year-old brother shrieked with pleasure as they emerged from the shadows to bump into
each other in the protective presence of their father.
These games, transmitted from generation to generation and present in many
cultures, give testimony to the importance of “make believe” as a shared psychological
mechanism where the players create a social consensus to experiment with reality by
setting up mock anxiety-arousing situations and bringing them to a reassuring happy end.
Movement and physical action
Children who are grieving often manifest their sadness through a loss of zest.
They move slowly and often seem lethargic. A regression or disorganization of motor
milestones may occur. Some children are overly careful, withdrawing from ageappropriate physical activities and becoming excessively sedentary. Others become
clumsy, bumping into things, falling frequently, or hurting themselves. Still other
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children can become accident prone, run away, engage in impulsive action, and defiantly
refuse to slow down or to stay close to the parent. Through other physical withdrawal,
clumsiness or recklessness, these children convey similar messages: they feel endangered
and in need of protection. The treatment needs to incorporate specific attention to these
unspoken requests for help.
The physically withdrawn child needs to be gently coaxed into age-appropriate
physical activities, both during the therapeutic session and in daily life. Toys during the
sessions may include a small soft ball that can be used indoors, or a gym ball that can be
used to encourage experimenting with balance. Going outdoors, including a playground,
can be the focus of some sessions, particularly if the parent also needs the therapist’s
supportive presence to expand the child’s opportunities for physical activity. Encouraging
physical pursuits can go hand in hand with supporting the work of mourning, as shown in
the following example.
Example. Jennie, 5 years old, developed a refusal to go to the playground since
her father died that had reached phobic proportions. Although the playground was only
two blocks from her home, she did not want to go there and cried when her mother
insisted that they go. This resistance progressed to not wanting to go by the playground
on her way to preschool. This was a place where Jennie and her father, an avid athlete,
went alone together on a regular basis. Jennie’s avoidance could be understood as an
effort to fend off the painful contrast between her memories of being there with her father
and the reality that he could no longer push her on the swing or help her in the climbing
structures. She also may not have wanted to dilute those happy memories by having her
mother substitute for her father. Jennie extended her avoidance of the playground to other
physical activities. Formerly a rambunctious child who loved age-appropriate sports, six
months after her father’s death she had become progressively more sedentary. Watching
TV and playing with her dolls became her primary interests.
The therapy focused on helping Jennie re-enact playground scenes with the father
and daughter dolls, speaking to Jennie’s missing of her father and her wish that he were
still her companion in the playground. Jennie’s mother had the felicitous idea of buying a
young golden retriever, whose need for exercise became the occasion for daily walks and
for animated scenes of throwing him objects that he would retrieve. The mother spoke
during these activities about how Jennie’s father would have liked to go on walks with
them, and how much fun he would have had watching Jennie and the dog playing
together. The walks were gradually expanded to include the perimeter of the playground,
and eventually included the playground itself. On one such visit, Jennie’s mother feigned
to be tired and sat on a bench to rest. She then reminded Jennie of the times the child had
come there with her father, and evoked the father’s pleasure at watching Jennie try new
feats on the climbing structures. She then suggested playfully that Jennie help the dog
down the slide. Jennie joined in the laughter at imagining this scene, and the mother
suggested the dog might enjoy watching Jennie go down the slide. This became a
breakthrough in the child’s willingness to become physically active again.
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Example. Nathan, a rambunctious 3-year-old, missed is father terribly. He missed
the times his father spent with him at the park or in their living room tumbling together.
When his mother began taking him to the playground in their new neighborhood, Nathan
sought out the fathers and went to join in any games that the fathers might be playing
with their children. Overcoming her embarrassment, Nathan’s mother made herself
explain to the other fathers that her son’s father had recently died and he was missing him
very much. Without invitation but always accepted, Nathan would ask to jump up on the
back of a father or readily joined in a game.
Body-based interventions
Toddlers and preschoolers can be remarkably adept at learning deep breathing
and relaxation exercises, which can be incorporated in the sessions either as needed or as
an integral part of teaching the child what to do when feeling angry or scared. Massage
has been shown to have beneficial physical and psychological effects on infants, and
through the therapist’s example it can be incorporated to the parent’s repertoire for
soothing the child.
These body-based interventions can be supplemented by activities outside of the
sessions that are geared to increasing awareness and control of body sensations. Some
children can benefit from martial arts classes that stress patience, persistence, and
endurance as well as strength and boldness. Through a focus on not hurting oneself or
one’s adversary, these disciplines provide children with an opportunity to discharge angry
impulses in non-destructive ways. Yoga has been adapted for very young children as
well, enabling them to release physical and psychological tension.
As Bessel van der Kolk has put it, “the body keeps the score” in responses to
trauma and grief. It is highly advisable to expand the scope of psychotherapy by enlisting
the child’s body in the recovery process, whether through massage, breathing and
relaxation techniques, physical play, martial arts, yoga, or other forms of exercise.
Parents often welcome suggestions to incorporate these practices into their child’s
routine, particularly when the specific practice suggested by the therapist is already
consonant with the family’s cultural background and childrearing values.
Putting feelings into words
As the previous section makes clear, young children experience strong emotion
viscerally, through bodily sensations. Learning to translate these body sensations into
symbolic expressions that can be communicated to others is an important component of
the ability to regulate affect. For this reason, children who can put feelings into words
often function better emotionally, socially, and cognitively.
Depending on the child’s age, teaching the child how to recognize feeling and
give it the appropriate name takes a variety of forms. The most direct intervention is to
name the feeling when it is clear that the child is experiencing it: “You look like you are
angry right now”. The basic trilogy of “mad, sad, glad” represents the ABC of feeling and
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has immediate appeal to young children because the words rhyme and are easy to
pronounce.
Books. Children’s books are a wonderful tool in learning to identify and name
feelings. Finding out about other children’s experiences through stories that are
sensitively told and beautifully illustrated helps the child feel less alone with his own
difficult feelings. The resource section lists books that describe and illustrate how
children feel when different things happen to them, including books about dying.
These books can be read during the sessions and can also become part of the home
routine.
In reading the book, the clinician needs to pay attention to the child’s reaction,
and continue reading only if the child is receptive. A child’s refusal to listen is a signal
of lack of readiness that should be respected. In the course of reading, the clinician may
pause to point to the pictures and to elicit the child’s responses in order to convert the
reading into an interactive activity.
Story telling. Young children love story telling. “Tell me a story” is a timehonored child request that indicates a wish for emotional closeness by sharing a state of
mind with the adult. Telling stories that closely approximate what happened to the child
but involve an imaginary child enables children to tolerate emotions that might feel too
overwhelming if directly addressed in themselves. “I knew a child once who was 4 years
old who felt very upset because she thought her mommy had died because she had done
something really bad.” This venue can be particularly helpful for very sensitive or
emotionally withdrawn children who need an initial buffer from their own intense
emotions before facing them more directly. In joint child-parent sessions, the therapist’s
story telling can also model what might be for the parent a novel way of interacting with
the child.
Feeling charts. Charts that depict facial expressions for different feelings can
become a tool for joint exploration when a child is struggling with a new or unnamable
feeling. The therapist may say: “Let’s look at these pictures, and show me what face feels
like you right now”. The chart can also be used to revisit a sequence of feeling and
illustrate how the child’s feelings changed as the sequence unfolded. For example, the
therapist may say, after the child emerges from a bout of aggression: “Let’s tell a story
about what just happened”, and encourage the child to point to the different facial
expressions, ending with how the child is feeling at the present moment. This and similar
exercises can help the child acquire and consolidate an “observing ego” by encouraging
self-observation with the adult’s support. Pointing out that it is possible to have two
conflicting feelings at the same time helps children more accurately describe their
emotional experience. “I’m happy that today is my birthday but sad that my mommy isn’t
here to share it with me.”
Letter Writing. Writing a letter to the lost parent can enable children to put intense
feelings of longing and love into words that build a symbolic bridge to the parent. For
preschoolers, who cannot yet know how to write but are able to speak about their
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feelings, dictating a letter for the parent can take the place of writing. This letter can be
put in a special place such as a treasure box, where the child might also keep other
mementos of the parent.
Preschoolers can be remarkably eloquent in expressing their longing through a
letter to the parent. Angelina, 4 years old, dictated this letter to the therapist: “Daddy,
why did you leave me forever? You used to love me and call play with me, why did you
go away?” This letter gave the therapist a chance to sympathize with Angelina about her
intense wish for her father to come back, and to tell her that he did not want to leave her
but he did not have a choice because he was so very sick.
Example. Jossy, age 5, was asked if she would like to draw a picture of her mom.
Jossy quickly got out a marker and started to draw. The therapist asked her what her
mother was doing in the picture and Jossy replied, “mami is washing the dishes.” The
therapist asked “where is mami” and Jossy replied “in the kitchen.” The therapist then
asked, “where is mami now? Jossy said, “she’s in heaven.” As she said this she appeared
sad and the therapist suggested “Let’s make a little book about mami.” When Jossy was
asked what she wanted to say in her book, Jossy stated, “mami is in heaven because she
died.” When asked if there was anything else she wanted to tell her mami in the book she
said, “Jossy loves you!” The therapist said to Jossy, “You really miss mami and love
her.”
Making a memory book. The making of a book provides a place for a child to
express feelings about the death of a parent. It can begin with remembering who told the
child that the parent had died and what they said. This is an opportunity to clarify
distortions as well as learn how the child conceptualizes the death of the parent.
Sometimes a child will use the book to tell a parent something about what is happening in
their life that they want the parent to know or to say how much they miss and love the
parent. Feelings can be expressed through pictures as well as words. Pages can be
designated for drawing pictures related to all the common feelings following loss:
sadness, anger and fear.
A memory book of favorite pictures and activities done with the parent can be
assembled with photographs and words as a way of holding onto the special qualities of
the relationship. It is not uncommon for a child to idealize the lost parent. Fantasy images
of the parent may replace what took place in actuality. A 3-year-old boy whose father had
in reality had very little contact with him stated, “My daddy carried me on horseback all
over the house.” and “My daddy took me to the park all the time.” These creations and
idealizations serve a defensive role, and also help the child hold onto the feeling that he
was important and valued in her parent’s mind.
Prosocial behavior as a means to master aggressive impulses
Helping others is often the best way to help oneself, for children as well as for
adults. The following example illustrates how the therapist addressed Gilliam’s recurrent
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biting problem, which led his teacher to warn the family that he might have to be
expelled from the child care center.
“I pulled out an alligator puppet with a big mouth and lots of teeth and introduced
Gilliam to Leo. I told Gilliam that Leo had a big problem: he keeps biting people and it
hurts and people get so upset that it ends up making him feel very bad. I demonstrated
Leo’s biting as I spoke. Gilliam listened intently. He took the alligator and bit his own
arm with it and yelled out ‘ouch’. He told me that he could see blood. I asked him if he
had any ideas to help Leo stop biting, since he had been able to stop biting before.
Gilliam ran to get the toy telephone and called Leo. He said to Leo: “Come home right
now!” When Leo “arrived”, Gilliam told him he could not bite people but he could bite a
toy, and helped Leo enact biting a toy. As he turned to other themes during the session,
he periodically turned to Leo and said “Don’t bite”. I stressed that Leo cries big crocodile
tears after he bites because he first wants to bite but then is sad that he hurt people and
people are mad at him. Gilliam kept Leo by his side throughout the session”.
CONCURRENT THERAPEUTIC MODALITIES
The traditional therapeutic modalities -- child-parent psychotherapy, individual
psychotherapy with collateral meetings, family therapy, and developmental guidance -can be supplemented with concurrent therapeutic modalities when the family
circumstances call for a more comprehensive approach to intervention. These concurrent
modalities are described below.
FAMILY SUPPORT: CREATING A PROTECTIVE ENVIRONMENT
Supporting the family in creating a safe framework where the child feels accepted
and helped in his grief is a crucial component of treatment. The home remains the central
element of the young child’s life, and the therapeutic work is unlikely to be optimally
effective unless psychological bridges are built between the therapeutic setting and the
home environment.
Helping the family in this process should start as early as possible in the course of
treatment, and during the assessment if this is possible. Some elements that contribute to
the creation of a supportive family framework are described below.
Identifying a surrogate primary caregiver
The single most important concrete action a therapist can take on behalf of the
child is to assist if necessary in identifying and supporting the adult who will take
primary care of the child following the parent’s death. When the family is relatively
stable and cohesive, this is often a self-evident decision. However, when the family faces
chaotic circumstances and a changing composition, this can be a heart-rending and timeconsuming process that calls for the therapist’s utmost internal balance and devotion to
the child’s well-being.
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The child will face different demands in adjusting to the death depending on the
nature of his relationship with the surviving parent. If the surviving parent has always
been intimately involved with the day-to-day care of the child, the child will be able to
rely on a close emotional relationship and familiar daily patterns while grieving the loss
of the other parent. On the other hand, if the surviving parent has been relatively
uninvolved in the child’s life, then the child will have the challenge of building a new
kind of relationship with this parent while simultaneously grieving for the lost one. In the
first case, the assessment needs to lay the groundwork for helping the surviving parent
understand the importance of maintaining familiar routines. In the latter case, the
assessment must include the dyad in creating new caregiving routines that may or may
not incorporate some of the old patterns.
If both parents have died, the clinician must work with surviving family members
to identify the person best equipped to undertake the important role of primary caregiver
for a grieving child. While respecting the family’s values about who should raise a child,
the clinician must be candid in discussing the hardships involved in the care of a grieving
child, and must be able to help the family evaluate realistically who can make the
required commitments of time and emotional energy. The clinician must also assess
whether the new caregiver is committed to the long-term care of the child in order to
prevent additional transitions and losses.
It must be admitted that the clinician has only the power of moral persuasion in
helping shape the family’s decisions, and that the limitations of the family circumstances
may dictate a course of action that is not optimal for the child. Nevertheless, the
therapist’s supportive presence as the family struggles with difficult decisions sets an
important emotional tone about how to handle emotionally laden issues with respect and
compassion for the feelings of all the parties involved.
Preserving reassuring reminders
Sometimes surviving family members believe that the deceased parent’s
belongings will only serve as painful reminders of the absent parent. On the contrary,
children benefit from the physical continuity of their surroundings in the midst of
emotional crises. It is important to bring up this topic early in treatment, in order to
educate family members about the importance of not discarding toys, clothes, books,
furniture and other belongings associated with the deceased parent.
Young children are not well able to hold onto internal representations of a lost
parent, and they need to rely on concrete physical reminders. Some items have special
meaning to the child and therefore are particularly important to keep. For instance, a 3year-old boy proudly retrieved a small car from his room to show to the therapist, saying:
“my mommy got it for me.”
Pictures of the parent are particularly valuable for the child, both at the time of the
death and for the future. A young woman who was adopted at age 4 after losing her
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mother sought out the child-parent therapist who treated her and her dead mother and
asked if the therapist had any memories of her mother. The therapist offered a photograph
that the mother had given her before her death. The young woman, now 21, said tearfully:
“I look so much like her”, and kissed the picture.
Some cultures have evolved psychologically sustaining rituals where the
community comes together in helping children cope with parental death. In South Africa,
relatives assist in assembling “memory boxes” for young children who are losing a parent
to AIDS. The box is a treasure chest of memories that include photos, special objects
such as jewelry, handwritten notes from a parent which might include dreams for the
child and hopes for their future. Audiotapes may contain a story read by a parent,
memories of experiences together, and family myths that can be passed onto future
generations.
Other reminders come in the form of rituals: lighting candles, saying prayers,
singing songs.
Example. A foster mother made up a song to comfort two little girls, ages 3 and
5, whose mother had been killed. During one session, Jossy sang this song. It was a
beautiful song “about mamacita Maribel… I bring you flowers because you are so
beautiful. I know you’re up in the sky watching over me.” Jossy sang this song over and
over and her sister Lillian wanted to join in but didn’t know the words so she hummed
along. The therapist commented: “It’s nice to have a song when you’re thinking about
your mommy.”
Example. A grandmother planted a garden choosing plants that specifically
attract butterflies. Her deceased daughter’s nickname was “butterfly.” Gilliam, at age 3,
would stand in the garden searching for butterflies. He would call out “mama mama” as
they approached and “bye mama” as they flew away.
Deciding whether to take a child to a wake or funeral ritual
Parents and caregivers can be helped to think about the appropriateness of
including a very young child in certain traditional practices, such as going to the funeral
or viewing the open casket, by discussing what the parent wishes to achieve through this
practice, anticipating how the child might respond, and suggesting alternatives that might
be better suited to the child’s capacities when necessary. Regardless of whether a child
attends the funeral service of their deceased parent or not, opportunities to grieve are
essential to a successful resolution to their loss.
Example. A mother wanted to take her toddler to his father’s funeral so the child
could say good-bye and see where the father would be buried. In reviewing what this
experience would be like for the child, the mother concluded that her shy little boy,
already suffering from his father’s loss, could feel overwhelmed by the many unfamiliar
people expected to attend. The mother also realized that neither she nor the child’s
grandparents might be fully available to the child during the funeral because of their own
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grieving and the social demands of the occasion. She decided to leave the child with good
friends instead, and planned to take him to the grave at a later time, when she could
prepare him in advance and devote all her attention to his experience.
Maintaining the child’s connection with the memory of the deceased parent
While it is important that a child understand the finality of death and that the
deceased parent will not be returning, it is equally important that the child believe that he
or she continues to exist in the deceased parent’s mind. The surviving parent and the
caregivers often need help in facilitating this process because they worry that the child’s
continuing psychological connection with the dead parent may mean that the child is
involved in a pathological inability to let go of the dead parent.
Parents can be helped to facilitate the child’s connection with the memory of the
deceased parent by reminding them that all cultures have developed sets of belief to
explain what happens when people die. Sometimes, but not always, the deceased are
expected to come back to life in some form. Across religions and spiritual practices, there
is a tradition that humans can communicate with the dead person’s spirit and that this
spirit can provide guidance and support.
Psychotherapy with young children should make room for the same approach,
upholding the spiritual traditions of the family and reassuring the child of his continued
existence in the mind of the deceased parent. This approach can take a variety of forms.
For example, the therapist may encourage caregivers to make statements such as, “your
mommy will always love you very much” or “it always makes your daddy happy when
you’re happy”, which serve to reassure the child of an ongoing bond with the dead
parent. It is also helpful to assure the child that it is good and permissible to reach out to
the dead parent. The surviving parent can say, for example, “Even though your mommy
went away, we can always talk to her inside of us”. It is reassuring for children who feel
alone and abandoned to realize that they can take action to feel less forlorn.
Example. One preschooler who was very distraught and only talked about herself
in the third person since her father died only recovered when she was assured that she
remained alive in the mind of her father. At her mother’s suggestion, this child wrote a
letter to her daddy reminding him not to forget her birthday. She attached her letter to the
string of a large balloon and released it into the air. Someone found the balloon and
responded to it with a letter and a present. The letter stated that her father had asked for
help with the shopping because he was not able to do it any more. After receiving the gift
and the letter, the girl no longer referred to herself in the third person.
Helping to assuage the surviving parent’s guilt
Adults often feel guilt when a child’s parent dies because they feel that, no matter
how much they try, they cannot be available enough and responsive enough to the child’s
needs. A common byproduct of this guilt is a tendency to over-indulge or over-protect the
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child. Indulging a child following the loss of a parent is an understandable and common
phenomenon. Expectations of appropriate behavior on the child’s part are suspended, and
the daily routine of naptime, bath time and bedtime may be given up in response to the
child’s refusal. The child may be showered with new toys, sweets and other atypical
forms of indulgence. This is not good for the child because it generates a feeling that the
child is entitled to special treatment because of the loss, and justifies a feeling of
entitlement based on sorrow that endows the grief with a dangerous element of secondary
gratification. The therapist can help by reassuring the parent that children who are
grieving need to retain a sense of purpose, predictability and accountability in their lives,
and that clear expectations and daily routines help to foster a sense of strength and
competence.
Helping the child cope with separation anxiety
After suffering the loss of a parent, the child can become very alert to the comings
and goings of important others. While it is sometimes easier to slip out the back door so
as not to momentarily upset a child, this behavior can have damaging long-term outcomes
because it reinforces the child’s conviction that she will be abandoned again when she
least expects it. The parent needs to be helped to always prepare the child when a
separation will take place, and to describe when the reunion will follow. These
explanations need to be done in simple language that is geared to the child’s level of
understanding. Examples include: “I am going to school now and will be home by the
time you wake up from your nap.” “I will be back to pick you up at the end of the day
just like always.” Helping the child anticipate departures and reunions, especially if they
are different from the daily routine, allows the child to master anxiety. One useful
strategy is to review the child’s daily schedule at bedtime or in the morning soon after the
child wakes up.
A child can also be very aware that a parent is emotionally unavailable due to
grief and depression. It is important to reassure a child that “mommy is sad because she is
missing daddy but she will feel better.” The child needs to know that the level of grief
that family members are exhibiting will decrease over time and that nobody in the family
will be sad forever.
Some children show their separation anxiety by refusing to return to their
childcare arrangement for fear something bad will happen when they are away from the
home. They believe that their mere presence in the home will avert further tragedy. These
children need to be reassured and sometimes to take a comforting object such as a
favorite blanket or stuffed animal with them to school. A call in the middle of the day to
simply check in can also serve to allay the child’s fears.
Managing anniversaries
Anniversaries are difficult for the entire family, not just the child. The therapist
needs to help the family anticipate these difficulties. It is easy for most people to
understand that they may have more thoughts and feelings about the deceased person
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around the anniversary of the death. What may be more surprising to them is that they
may be more distractible or anxious, may have trouble sleeping, and may have appetite
disturbances around anniversaries. Young children may become more clingy, more
oppositional, or may regress developmentally. The therapist should help caregivers
anticipate these responses, their own and the child’s, and explain behaviors when they
happen in terms of anniversary responses.
DAY CARE CONSULTATION.
Daycare teachers can be powerful allies in helping children during the process of
mourning. At their best, preschool settings offer dependable caregivers, predictable
routines and opportunities for children to develop trust with figures outside the immediate
family. As an adjunct to parent-child or individual treatment, supportive collaboration
with preschool teachers can go a long way in helping a child recover and move along a
normal developmental trajectory.
The clinician can inform the childcare provider about the predictable responses to
the parent’s loss, including increased crying and lowered tolerance to frustration,
regression in developmental milestones such as losses in toileting skills and reverting to
baby talk, and increased aggression. Predicting these behaviors before they occur or
explaining them in the context of mourning responses while they occur can help childcare
providers and teachers anticipate, closely observe and plan how to respond sensitively.
For example, holding a young child during nap time may be exactly the soothing ritual a
child is yearning for. Other examples include the need to respond immediately in a
protective and soothing manner when a child develops a tendency for self-injury, and the
need to engage a child who has retreated into a corner and reintegrate him into the group.
Maintaining relationships that have been in place is paramount in helping a child
feel safe and secure. When appropriate, the clinician may advocate that the bereaved
child not be moved up to the next classroom level but rather remain with a familiar
teacher, peers and classroom for a more extended period of time. Pictures of the deceased
parent and remaining family members can be kept in a cubby that is easily accessible to
the child to provide a necessary soothing function in the grieving process.
Example. Jonathan, at age 3, kept pictures of his deceased parents in a backpack
which he refused to take off for weeks. Every once in awhile he would take the pictures
out to look at them. As other children approached him wanting to see what he was doing,
he quickly put them away stating loudly and assertively “you can’t see.” Jonathan needed
to have his parents to himself. He was not yet ready to share his loss with his peers.
Eventually Jonathan placed his backpack in his cubby, not needing to have the pictures in
such close proximity. When ready, he was helped to show the pictures to his classmates.
Teachers need to be sensitive to special days like Mother’s Day, Father’s Day and
other holidays where children typically make cards and artwork for their parents. It is
important to introduce the activity by giving a lot of room for the inclusion of significant
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others (aunts, uncles, grandparents, godparents) and to anticipate sadness in the child who
has suffered the loss of a parent.
Other children in the classroom are likely to very upset on learning that a child
has lost a parent. Due to their own fears that such a tragedy may befall them, other
children may avoid the bereaved child. Teachers need to facilitate play that includes
themes of loss and to relieve the anxieties of the other children. Reassurance is called for
on a number of levels: the bereaved child; the other children at the center; and the parents
of the children in the classroom, who may be the recipients of the bereaved child’s anger
and hostility or, alternatively, or the child’s wish to “adopt” them as the new parent.
Parents of other children at the daycare center may wish to assist the surviving
parent by cooking, planning joint play dates or having the child over by him or herself
providing opportunities and space for the parent to mourn.
CRISIS INTERVENTION AND CONCRETE ASSISTANCE WITH PROBLEMS OF
LIVING
Many families face overwhelmingly stressful circumstances that may precede the
parent’s death or be the result of it. The clinical work needs optimally to take these
circumstances into account because they have a major impact on the child’s capacity to
mourn effectively. Some therapists work with a multimodal approach where they move
seamlessly between different modalities, including developmental guidance, insightoriented intervention, crisis intervention, and concrete assistance (Fraiberg, 1980;
Lieberman & Pawl, 1993). Other therapists work within a specified modality, but make
referrals to community services as needed. When referrals are made, it is often crucial for
the therapist to follow up on these referrals to ensure that they yield the desired outcome.
Bereaved parents often do not have the know-how or the emotional resources to advocate
for themselves, and their needs may be overlooked or minimized by systems of care that
are underfunded and overused. The skillful advocacy of a professional is often essential
to make sure that families receive the services they need.
THERAPIST'S EMOTIONAL REACTIONS
Working therapeutically with a small child who is bereft by the death of a parent
evokes intense emotional responses in the clinician, who may experience strong sadness
and grief that reflect the child's own feelings. These responses may be relatively
circumscribed to the therapeutic sessions, but they may also infiltrate the therapist's life
outside of work. When this occurs, the therapist may feel listlessness, hopelessness, lack
of energy, a pervasive sense of pessimism or fatigue, or may become irritable and easily
overwhelmed by minor frustrations. The therapist may not be aware that these feelings
are triggered by unconscious responses to the bereaved child.
The therapist's responses are often especially powerful when the child is not
receiving appropriate enough care from his surrogate caregivers. The therapist may feel
angry that nobody empathizes sufficiently with the child's pain, and may feel all alone in
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the task of helping the child during the grief and mourning process. Fantasies of adopting
the child or of confronting the surrogate parent may become pervasive and interfere with
the therapist's sense of inner balance in working with the child and the family.
Self-knowledge and self-scrutiny are time-honored methods for striving towards a
psychological stance that protects the therapeutic process by helping the therapist
remember her circumscribed role in the child's life and respect and support the role of
other caregivers. Zero to Three: National Center for Infants, Toddlers and Families
recommends the use of reflective supervision (Zero to Three), a consultation and
supervision modality where the clinician carves out the time to reflect on her experiences
with a supportive, more experienced supervisor. Reflective supervision gives the clinician
permission to describe in detail what happened during a session and to explore in depth
the feelings about the work without fear of being judged or criticized by the supervisor.
This is particularly effective in working with emotionally wrenching clinical situations
that have a profound impact on the clinician’s state of mind, such as child maltreatment
and bereavement. While an essential training tool in formation of mature and selfconfident clinicians, reflective supervision is unfortunately not an integral component of
most mental health agencies. Administrators, supervisors, and clinicians can contribute to
the widespread practice of reflective supervision by advocating for the importance of
devoting financial and time resources to supporting the clinician in this difficult but
essential effort to promote young children’s mental health.
CONCLUSION
The death of a parent represents a cataclysmic event in the psychological
landscape of a young child. As the importance of the first five years of life as the
foundation of neurophysiological, emotional, social and cognitive functioning becomes
increasingly well elucidated, the negative impact of traumatic stress becomes better
understood. These guidelines are designed to enable clinicians to provide a
comprehensive assessment to young children who lost a parent, and to help them develop
a treatment plan based on the centrality and continuity of primary caregivers when risk
factors are identified for the child’s unfolding development and mental health.
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BOOKS AND RESOURCES
CHILDREN’S BOOKS ABOUT DEATH
Touchpoints: The Essential Reference
When Dinosaurs Die: A Guide to
Understanding Death
The Runaway Bunny
The Dead Bird
The Fall of Freddie the Leaf
Cognitive Behavioral Therapy for
Traumatic Grief in Children Treatment
Manual
Daddy’s Promise
You Go Away
Remembering Mama
Healing After Trauma Skills: A Manual for
Professionals, Teachers, and Families
Working with Children after
Trauma/Disaster
Goodbye Mousie
Lifetimes: The Beautiful Way to Explain
Death to Children
Your Baby & Child: From Birth to Age
Five
The Goodbye Boat
Gentle Willow: A Story for Children about
Dying
I Heard Your Mommy Died
I Heard Your Daddy Died
Help me say Goodbye: Activities for
Helping Kids Cope when a Special Person
Dies
Saying Goodbye to Daddy
The Tenth Good Thing about Barney
Granddad’s Prayers of the Earth
T. Berry Brazelton, M.D.
Marc Tolon Brown, Laurie Krasny Brown
(Illustrator)
Margaret Wise Brown, Clement Hurd
(Illustrator)
Margaret Wise Brown
Leo F. Buscaglia, Ph.D.
Center for Traumatic Stress in Children
and Adolescents, Dept. of Psychiatry,
Allegheny General Hospital, Pittsburg,
PA
Cindy Klein Cohen, John T. Heiney,
Michael J. Gordon (Illustrator)
Dorothy Corey, Diane Paterson
(Illustrator)
Dara Dokas, Angela L. Chostner
(Illustrator)
Robin H. Gurwitch, Ph.D. & Anne K.
Messenbaugh, M.Ed., L.P.C., University
of Oklahoma Health Sciences Center,
Dept. of Pediatrics
Robie H. Harris, Jan Ormerod (Illustrator)
Bryan Mellonie and Robert Ingpen
Penelope Leach
Mary Joslin, Claire S. Little (Illustrator)
Joyce C. Mills, Ph.D., Michael Chesworth
(Illustrator)
Mark Scrivani, Susan Aitken (Illustrator)
Mark Scrivani, Susan Aitken (Illustrator
Janis Silverman
Judith Vigna
Judith Viorst, Erik Blegvad (Illustrator)
Douglas Wood and P. J. Lynch
(Illustrator)
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BOOKS & ARTICLES ABOUT DEVELOPMENTAL ASSESSMENT
Toward an experimental ecology of human
development. (American Psychologist, 1977,
Vol. 32, p. 513-531)
The ecology of human development (1979)
Development in the preschool years: The
typical path. In E. V. Nuttall & I. Romero &
et al. (Eds.), Assessing and screening
preschoolers: Psychological and educational
dimensions (2nd ed.). (pp. 9-24). (1999)
Culture and early interactions (1981)
Assessment of social-emotional functioning
and adaptive behavior. In: see C.P. Edwards
Assessment of children: Cognitive
applications (4th ed., 2001)
Assessment of children: Behavioral and
clinical applications (4th ed., 2002).
U. Bronfenbrenner
U. Bronfenbrenner
C.P. Edwards
T.M. Field, A.M. Sostek, P.M. Vietze,
& P.H. Leiderman
H.M. Knoff, S.A. Stollar, J.J. Johnson,
& T.A. Chenneville
J.M. Sattler
J.M. Sattler
68
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TABLE OF CONTENTS:
PARENTAL LOSS IN INFANCY AND EARLY CHILDHOOD ............................... 4
TRAUMATIC LOSS ............................................................................................................ 7
REACTIONS TO PARENTAL LOSS IN INFANCY AND EARLY CHILDHOOD ........................... 7
Behavioral manifestations of grief and mourning. ..................................................... 7
Affective-cognitive processes in mourning ............................................................... 11
Effects on the child of caregiver reaction to the death ............................................. 12
THE ASSESSMENT PROCESS ................................................................................... 15
FACTORS AFFECTING A CHILD’S BEREAVEMENT PROCESS ........ ERROR! BOOKMARK NOT
DEFINED.
ASSESSMENT DOMAINS.................................................................................................. 16
1. The child’s emotional, social, and cognitive functioning. .................................... 17
2. The child’s relationship with the deceased parent. .............................................. 19
3. The child’s network of relationships. .................................................................... 20
4. What the child knows about the parent’s death. ................................................... 21
5. Cultural and family traditions and beliefs regarding death and dying. ............... 22
6. Family childrearing values and plans to care for the child.................................. 22
7. The family’s general strengths and vulnerabilities. .............................................. 23
DIAGNOSTIC EVALUATION ............................................................................................. 23
Differential diagnosis between bereavement and traumatic response ..................... 24
Prolonged Bereavement/Grief Reaction ................................................................... 24
Traumatic Stress Disorder ........................................................................................ 25
THE TREATMENT PROCESS .................................................................................... 27
TREATMENT MODALITIES .............................................................................................. 27
Child-parent model ................................................................................................... 27
Family therapy model ............................................................................................... 29
Individual child psychotherapy/ collateral sessions with parent .............................. 30
Developmental guidance ........................................................................................... 30
THE THERAPEUTIC SETTING .......................................................................................... 32
Home Visiting............................................................................................................ 32
The clinic playroom. ................................................................................................. 32
Community settings ................................................................................................... 33
UNFOLDING AND CONTENT OF THE THERAPEUTIC PROCESS .......................................... 33
Treatment Goals........................................................................................................ 33
CONDUCTING THE TREATMENT ................................ ERROR! BOOKMARK NOT DEFINED.
Formation of the therapeutic relationship ................................................................ 35
What and how to tell the child about the parent’s death .......................................... 36
Explaining the idea of death to a child ..................................................................... 39
Addressing Children’s Fears .................................................................................... 43
Consolidating positive and negative feelings about the lost parent ......................... 46
Modeling manageable separation: therapist’s vacation and treatment termination 47
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THERAPEUTIC STRATEGIES AND TOOLS .......................................................................... 50
Choosing therapeutic toys......................................................................................... 50
Play ........................................................................................................................... 51
Games ....................................................................................................................... 53
Movement and physical action.................................................................................. 54
Body-based interventions .......................................................................................... 56
Putting feelings into words ....................................................................................... 56
Prosocial behavior as a means to master aggressive impulses ................................ 58
CONCURRENT THERAPEUTIC MODALITIES .................................................... 59
FAMILY SUPPORT: CREATING A PROTECTIVE ENVIRONMENT ......................................... 59
Identifying a surrogate primary caregiver ............................................................... 59
Preserving reassuring reminders .............................................................................. 60
Deciding whether to take a child to a wake or funeral ritual .................................. 61
Maintaining the child’s connection with the memory of the deceased parent .......... 62
Helping to assuage the surviving parent’s guilt ....................................................... 62
Helping the child cope with separation anxiety ........................................................ 63
Managing anniversaries ........................................................................................... 63
DAY CARE CONSULTATION. .......................................................................................... 64
CRISIS INTERVENTION AND CONCRETE ASSISTANCE WITH PROBLEMS OF LIVING ............ 65
THERAPIST'S EMOTIONAL REACTIONS ............................................................. 65
CONCLUSION ............................................................................................................... 66
BOOKS AND RESOURCES ......................................................................................... 67
CHILDREN’S BOOKS ABOUT DEATH ............................................................................... 67
BOOKS & ARTICLES ABOUT DEVELOPMENTAL ASSESSMENT .......................................... 68
REFERENCES ................................................................................................................ 69