Mary Hildreth and Melanie Hickey
Bereavement Coordinators
Iowa Hospice
Define loss, mourning, grief and bereavement.
Distinguish between anticipatory grief, normal
grief, complicated grief and disenfranchised grief
and how it can be different for children.
Learn about treatment interventions to use with
children to teach coping strategies for their grief.
What does grief look like?
Is this what
grief should
look like?
What
about this
child?
Are they
grieving?
What
about
this boy?
The Grief Process
 “There are no mistakes, no coincidences. All
events are blessings given to us to learn
from.”
 ~Elisabeth Kubler Ross~
 Grief is a multi-faceted response to loss, particularly to the
loss of someone or something to which a bond was formed.
Although conventionally focused on the emotional
response to loss, it also has physical, cognitive, behavioral,
social, and philosophical dimensions. (Wikipedia)
 The loss may be a person, thing, relationship, or situation.
 Bereavement is the reaction of the survivor to the death of
a family member or close friend.
 Children and adolescents may experience grief differently
from adults
 They may react differently to the death of someone close to
them or even when experiencing a loss just from being
apart from their family, whether in a group home or in
foster care.
 When working with children who have experienced any
type of loss, it is important to be aware of their
developmental stage and any cultural considerations.
Normal Grief (Uncomplicated)
 Normal feelings, behaviors and
reactions to loss
 Physical, emotional, cognitive and
behavioral reactions.
Types of Grief
 Anticipatory Grief
 Normal Grief (Uncomplicated)
 Complicated Grief
 Disenfranchised Grief
 Children’s Grief
Anticipatory Grief
 Grief before loss
 Actual or fear of potential losses
 Experienced by patient, family, and
professionals
 Children have unique needs
Complicated Grief
 Chronic grief
 Delayed grief
 Exaggerated grief
 Masked grief
Complicated Grief ~ Risk Factors
 Sudden or traumatic death
 Suicide, homicide
 Death of a child
 Multiple losses
Disenfranchised Grief
 When loss cannot be openly acknowledged or socially
sanctioned
 At risk ~ AIDS partners, ex-spouse, step-parent/child,
terminated pregnancy
Children’s Grief
 Based on developmental stages
 Can be normal or complicated
 Symptoms unique to children
Factors Influencing the Grief Process
 Survivor personality
 Coping skills, patterns
 History of substance abuse
 Relationship to deceased
 Spiritual beliefs
 Type of death
 Survivor ethnicity and culture
5 Stages of Grief
Denial
Anger
Bargaining
Depression
Acceptance
Denial
 “No not me”
 When a person receives news of a loss be it death or
another kind of loss they may be in denial that the loss
actually happened.
 We may tend to deny the loss has taken place and may
withdraw from our usual social contact. This stage may
last a few moments to a few months.
 In residential care it may look like, “My family will be
here soon to pick me up.” The child stands by the door
and waits.
Anger
 “Why me?”
 May be furious at the person who inflicted the hurt (even if
they are the one who died), or at the world, for letting it
happen
 May be angry with himself for letting the event take place,
even if, realistically, nothing could have stopped it (magical
thinking).
 In residential care, “I hate Social Workers. They don’t
understand me or my family. They lied about my family, my
dad would not have done that!” May cry uncontrollably or
become angry when asked to do simple requests.
Bargaining
 A person can bargain with God, others, or themselves
to alleviate grief.
 In residential care, the child may now realize they they
will be in their placement for an extended period of
time. They may say, “If I’m allowed to go home, I
promise to be good and do what I am told.”
Depression
 The person first mourns past losses, things not done,
and wrongs committed.
 They may feel numb, although anger and sadness may
remain underneath.
 In residential care, “Who is going to take care of me?
Did I make this happen? I give up. Why me? I’m so
alone.”
Acceptance
 The person has accepted the loss or the reason why the
loss happened. They have accepted the change.
 I’m here in this home, but I’m safe. This is not my
fault. I did not make this happen. Adults make choices
for me. I need to do my best to share my feelings with
adults around me that I trust. I will get through this
and be OK.”
Dynamic not Static
 Processing grief is not a linear process and is not neat
and tidy.
 It is not necessary to go through all stages.
 Be prepared to go back and forth between stages as
needed to process the situation.
 Watch for signs that someone may be stuck in one
stage. They may need additional support.
Long term effects of bereavement
on children
 Up to 40% of bereaved children show disturbance after
one year
 37% of prepubertal children in a recent study had a
major depressive disorder within one year of the death.
 Longing for reunion is common and may lead to
suicidal thinking in children but not usually acted on.
 Bereaved children are 5 times more likely to develop a
psychiatric disorder.
Coping with Loss: Bereavement in Childhood. By Dora Black
Age Groups
 We will look at the differences in grief reactions
according to developmental stages:
 Birth to age 2
 Ages 2 to 5
 Ages 6 to 9
 Ages 9 to 12
 Ages 13 to 19
https://www.bariumsprings.org/pilotFiles/pdf_documents/files/Grief%20and%20Loss.pdf
Birth to 2 years
 Types of loss would be the death of the primary caregiver,




loss of primary caregiver because of the birth of a sibling,
or removal from primary environment.
Sense of security and well being is challenged
Surroundings are no longer familiar
Child may display excessive crying, rocking, whining,
biting, and/or other anxiety related behaviors.
Child may not be able to process death as anything other
that separation anxiety.
Ages 2 to 5
 May have feelings of sadness, anxiety, insecurity, irritability




and anger.
Tend to believe that death is a temporary state that can be
reversed.
May equate death with sleeping or being gone on a trip.
Magical thinking may occur.
Some children will act as if nothing has happened while
others may regress in areas such as toileting or wanting a
bottle.
Ages 6 to 9
 Are able to understand the biology of death and
comprehend the finality of it.
 May develop fears associated with their own death or
the death of a surviving parent
 Feelings of insecurity may be expressed in a reluctance
to separate from caregivers.
 Some may be hyperactive, aggressive and disruptive,
while others are withdrawn and sad.
 May have nightmares, difficulty sleeping, or display
regressive behaviors.
Ages 9 to 12
 Understand that death is final and that it happens to
everyone.
 Continuity is important at this age. They may want to
go out and play instead of talking.
 They may have a strong need to control their feelings
while at the same time they have great difficulty doing
so.
Ages 13 to 19
 Adolescents may have difficulty coping with the loss
for months or years
 Want to be in control of their emotions so may isolate
from others.
 May engage in risk taking behaviors such as reckless
driving, drug/alcohol use, sexual promiscuity, cutting,
and/or defiance of authority.
 May become more easily distracted, experience
sleeping and eating disturbances, perform better or
worse in school, and display strong emotional mood
changes.
Unhelpful Comments
Helpful Comments
I know exactly how you’re feeling.
I am sorry that you are going through this painful
process.
I can imagine how you are feeling.
It must be hard to accept that this has happened.
I’m always here for you call me if you need
anything.
I can bring dinner over either Tuesday or Friday.
Which would be better for you?
You should be over it by now. It is time for you to
move on.
Grieving takes time. Don’t feel pushed to hurry
through it.
You had so many years together. You are so
lucky.
I did not know ____, will you tell me about him?
What was your relationship like?
At least you have your children.
It is not your fault. You did everything you could
You’re young, you’ll meet someone else.
What’s the most scary part about facing the
future alone without _________?
At least her pain and suffering is over. She is in a
better place now.
You will never forget ______ will you.
He lived a really long and full life.
It’s not easy for you, is it? What about your
relationship will you miss the most?
How old was he?
He meant a lot to you.
Do this
Do not do this
Know your own beliefs
Praise stoicism
Begin where the child is
Use euphemisms (died in his sleep)
Be there and be truthful
Be nonchalant
Confront reality and use touch to communicate
Glamorize death
Allow and encourage expression of feelings
Tell fairy tales and half truths
Include the child in family rituals
Encourage the child to be like the deceased
Encourage remembrance
Protect the child from exposure to experiences
with death
Admit when you do not know the answer
Encourage the child to forget and just get over it
Talk about death as it naturally occurs (change of
seasons, pets, current events)
Close the door to questions
Accept different reactions to death
Be judgmental of feelings and behaviors
BREAK
Death and Dying Simulation
Activity
Grief Interventions for
Survivors






Provide presence
Active listening, touch, silence, reassurance
Identify support systems
Normalize & individualize the grief process
Actualize the loss & facilitate living without deceased
Use bereavement specialist and resources
How can a Bereavent Counselor help?
 Bereavement Counselors are trained specifically in the area




of grief and loss.
They understand the different ways a person grieves
Access to various interventions to support the person
Can meet the person in their own home
Counseling is provided at no cost to the person
Bibliotherapy
 Jungle Journey: by Barbara Betker McIntyre
 Badger’s Parting Gifts: by Susan Varley
 Water Bugs and Dragonflies: by Doris Stickney
 Tear Soup: by Pat Schwiebert & Chuck DeKlyen
Hearts n Hooves
 One day camp for kids ages 7 to 17 who experienced a
death of a loved one.
 Designed to help kids communicate sorrow, manage
pain, and work through their grief by utilizing
activities with crafts and horses.
 2 locations: Timber Creek Therapies in Guthrie Center
and Juan Diez Rancheros in Davenport.
 Open to all children who qualify and there is no cost to
attend.
What else can we do to help?
 Remember to be honest and ask what the child wants
to know.
 Allow the child to see your emotions and tears.
 Do not try to fix the child, they need to process on
their own terms.
 Allow them to experience the death if appropriate and
warranted.
 Maintain a regular routine.
 Try not to expect more than they can give.
 Allow children to mourn small losses (pets) and be
open to discussion.
 Give them the opportunity to say goodbye.
 Use concrete terms and use language the child will
understand.
 Do not make promises that are out of your control.
LISTEN!
Myths and Facts
 I won’t say or do the right thing. *Just let them know you




are there for them.
They won’t want to talk about it. *Let it be their choice,
not yours.
I might upset them. *They are already upset and that is
okay.
They need to keep busy. *Not thinking about it can delay
their grief
Getting rid of reminders help. *This can send the
message that it is not okay to think about the person who
died.
Myths and Facts, cont.





I won’t mention unless they do. *Sends the message that there is
something bad about talking and they will sense your discomfort.
Once they have felt anger or guilt, that should be the end of it.
*Grief is circular and is life long.
It is morbid to want to touch or talk about the body. *This is healthy
and makes the death real but do not force it.
It is easier to say “passed away”. *These phrases can confuse or
frighten children.
If they are not showing emotion, they are not grieving. *They may
not know how to show emotion or are taking cues from the adults
around them.
Completion of the Grieving Process
 No one can predict completion
 Grief work is never completely finished
 Healing occurs when the pain is less
 You do not get over it, but you can get through it.
RESOURCES
 Black, Dora. Coping with Loss: Bereavement in Childhood. March 21, 1998. BMJ
Volume 316 p 931-933.
 Center for Loss and Change http://www.centerforloss.com/
 The Dougy Center: National Center for Grieving Children and Families.
www.dougy.org
 Earl Grollman: Talking About Death: A Dialogue Between Parent and Child
 Elisabeth Kubler-Ross Foundation http://www.ekrfoundation.org.
 https://www.bariumsprings.org/pilotFiles/pdf_documents/files/Grief%20and%
20Loss.pdf
 http://journeyofhearts.org/grief/kids_death.html
 Hospice Education Institute: www.hospiceworld.org
 Zucker, Robert. The Journey Through Grief and Loss. 2009. St.Martin’s Press,
New York