Children_Coping_Death_Dying by xiaopangnv

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									       Children Coping With Death & Dying
                            Presented by Nora Gravois, LMSW-IPR
                    Bereavement Coordinator for The Hospice of East Texas



Objectives
• Clarify Definitions
• Distinguish normal vs complicated grief
• Acknowledge children’s grief process & needs of grieving children
• Identify effective communication to talk to children about death and dying
• Encourage professional self care
                                    Bereavement
                                        Bereavement is the state of
                                          having suffered a loss.




Objective: Clarify definition
                                Objective: Clarify Definition
 Grief
Process of
experiencing
the
psychological,
social, physical
and spiritual
reactions to
the perception
of loss.




 Objective: Clarify definition
Anticipatory Grief
A normal mourning reaction
that allows emotional preparation for the loss.

 Objective: Clarify definition
                                           Mourning
                                  Conscious and unconscious processes
Objective: Clarify definition   that help the mourner adapt to the loss.
           Reinvestment/Accommodation
Reinvesting emotional energy into new constructive outlets.
                                 Preparing to “embark”




 Objective: Clarify definition
                 Children’s Grief




     Should we discuss death and dying with Children?

Shielding a child from conversations about death and dying deprives them
                    •of their own right and need to grieve
                             •of their need to mourn
                         •of their need to feel and heal
                 •of their need to experience reinvestment
                                                           Children‟s Grief
                                                       Why should we talk to children
                                                         about death and dying?



                                                   If we don’t
            Conveys a message of avoidance
    Avoidance lead to unhealthy feelings and emotions
                 Unresolved worry, fear
            Increased anxiety, apprehension
       Develops seeds for resentment and distrust
    Opportunity for unhealthy lifelong coping patterns

Objective: Effective Communication with Children
                                                        Children‟s Grief
                                                   Why should we talk to children
                                                     about death and dying?
                                                   If we do
     We will discover what is known vs. not known
                Clear up distorted thinking
                  Resolve fears, worries
               Provide needed information
           Demonstrate comfort, understanding
              Promote growth, coping skills
       Strengthen bond of supportive relationships
     Assurance and security lead to healthy coping
   Child learns to understand grief as part of life cycle
             that will support throughout life
Objective: Effective Communication with Children
  Children’s Normal Grief Reactions
         May be emotional
           Self blame
              Guilt
             Fears
  Helplessness/Hopelessness
             Anger
           Withdrawn
       Increased Anxiety



                                                         May be Spiritual
                                                     Challenges to belief system
                                                        Physical Confusion
                                                        A LOT of questions
                                                              “Why’s”
                                                       Where did he/she go?
                                                          What is “dead”?
Objective: Distinguish Normal vs Complicated Grief
 Children’s Normal Grief Reactions
                                                      May be Physical / Behavioral
                                                             Changes in appetite
                                                              Sleep disturbances
                                                                  Nightmares
                                                                Physical hurts
                                                                 Hyperactivity
                                                             Aggressive reactions
                                                       Increased volume/tone in speech
                                                               Passive reactions
                                                      Limited conversations, introverted
         May be Cognitive
      Reduced attention span
       Increased distraction
          Easily confused
           Exaggeration
         Magical thinking

Objective: Distinguish Normal vs. Complicated Grief
                                                         Complicated Grief
                                                                       DSMIV-TR


                                                          Prolonged, intense reactions that interfere
                                                            with daily function 6 months or longer


                                                     •   Symptoms overlap with depression diagnosis
                                                     •   Refusal to accept loss
                                                     •   Continued sense of disbelief, anger
                                                     •   Recurrent painful emotions
                                                     •   Preoccupation with thoughts of loved one
                                                     •   Distressing intrusive thoughts related to death
                                                     •   Intense longing and yearning

                                                         Referred to as traumatic, altered, pathological,
                                                          dysfunctional, abnormal, absent, inhibited,
                                                                    delayed, disenfranchised

                                                     NO SENSE OF RELIEF, REST OR SUPPORT

Objective: Distinguish Normal vs Complicated Grief
                           Complicated Grief Implications




•   Social interactions increase support and risk
•Tween & Teen individuation stretches adult-child relationships
•Increased possibility of unfinished business
•Increased possibility of anger, guilt, depression



Objective: Distinguish Normal vs Complicated Grief
                                                     Objective Assessment
                                                                        Normal
                                                                      Anticipatory
                                                                      Complicated
                                                     ************************************************************

                                            ?Tearfulness and general sadness
                                            ? Expression of emotions
                                            ? Physical Reactions
                                            ? Ability to Focus
                                            ? Desire & Motivation
                                            ? Ability to Function w/ daily activities

Objective: Distinguish Normal vs Complicated Grief
     Children’s Grief Concepts 0-2 years
                                     LM Aldrich, William Worden, Dan Schaefer, Christine Lyons




Understanding: Does not comprehend death
Aware of constant activity in home, others looking
“sad”, someone is “missing”

Reactions: Responds to emotions or feelings of adults
Crankiness, Crying, Vomiting
Regression in Toileting, Altered eating and sleeping
Clinging, Restless, Insecure, Scared

NEED: Reassurance
Wrap infant in soft blanket, maintain routine, physical assurance through
holding, quick attention to expressed reactions and needs



 Objective: Acknowledge Needs of Grieving Children
     Children’s Grief Concepts 2-5 years
                                     LM Aldrich, William Worden, Dan Schaefer, Christine Lyons




Understanding: Mostly live in present tense
Curious about death and life; see it as temporary, reversible
Death mixed up with trips, sleep, happens to other people
Engage in Magical, exaggerated thinking
Wonder what deceased is doing “underground”

Reactions: Trying to “Figure it Out”
May show little concern or Regress to infantile behavior, Fear separation
Need to talk about the death over and over, Confused

NEED: Consistency
Short explanations with real terms, fact of death, no catchy sayings,
Consistent Expectations for behavior
Respond to security needs
Don’t punish, instead explain and teach with repetition
Let the child tell the story over again
 Objective: Acknowledge Needs of Grieving Children
    Children’s Grief Concepts 6-9 years

                   “This particular group
          should be singled out for special concern.
                  They have insufficiently developed
                     social skills to enable them
                        to defend themselves.”

                                                    …William Worden




Objective: Acknowledge Needs of Grieving Children
      Children’s Grief Concepts 6-9 years
                                       LM Aldrich, William Worden, Dan Schaefer, Christine Lyons




Understanding: Clearer
Comprehending that they can die too; begin to question biology of death
Begins to fear Death; realize that death is final; people they love can

Reactions: Highly emotional
Crying, high anxiety, anger, cranky, aggression, hyperactivity
Decline in school performance, involvement
Greif reactions ebb and flow; less willing to talk about death
More fearful questions and thoughts about “what will happen if…”

NEED: Honesty
Refrain from using cliché's
Respond passionately; be responsive without judgment
Reassurances with clear expectations of appropriate behavior
Use of art and stories

Objective: Acknowledge Needs of Grieving Children
Children’s Grief Concepts 9 - 12 years


                 “This age concentrates on
               the disruption death causes.”
         “Do we have to move because daddy died?”
  ”Now grandpa won’t be able to take me fishing”.

                                                    …William Worden



Objective: Acknowledge Needs of Grieving Children
     Children’s Grief Concepts 9 -12 years
                                         LM Aldrich, William Worden, Dan Schaefer, Christine Lyons




 Understanding: Death is very personal
 A more realistic view of death; can differentiate between dead and alive
 Increased curiosity / research about biological aspects of death
 Begin to understand that death is “forever”

 Reactions: Separation Anxiety
 Fear, reluctant to leave safe adults or home
 Boys may lose some manual skills; aggression appears hostile
 Anger, Guilt, Distancing, Anxious, Worried, Isolated
 Decline in performance, grades, involvement

 NEED: Permission with appropriate expectations
 Give compassionate answers, comfort, reassurance
 Permission to vent feelings; provide honest explanation of death
 Listen attentively, Use appropriate touch (with permission)
 Include in discussion of ways to honor & remember loved one
Objective: Acknowledge Needs of Grieving Children
    Children’s Grief Concepts Teen yearsLM Aldrich, William Worden, Dan Schaefer, Christine Lyons



Understanding: More adult processes evident
Able to think abstractly; Understands implications of death
Talks about feelings of immortality; realize death is fragile

Reactions: Assumes the adult role
Fearful of future, preoccupied with thoughts of death
May need to protect or stay close to loved ones
Anger and aggression, May exhibit “risk-taking” behavior
Withdrawn, Quiet, Loud, Lonely, Sad, Worried

NEED: Communication & Connection
Encourage communication “when you can”
Physical touch very important, but ask permission
Engage in loving confrontation
Involve trusted friend
Provide professional help if necessary
Objective: Acknowledge Needs of Grieving Children
                            Common Misconceptions
  “Children do not                                                        “Children don‟t
  understand death”                                                       grieve”



        “Attending a                                                      “Talking
       funeral is not                                                     makes it worse”
          good for
         Children”
                                    “Children don‟t really know
                                    what‟s going on”
                                                           “Silence means okay”
                 “Children will be scared
                 if they find out the truth”
                                                  “Child is young, won‟t
                                                  remember”
 “Children are just little adults”

                                                    “It‟s best not to bring it up”
Objective: Acknowledge Needs of Grieving Children
       Common Mistakes that Adults Make
  Minimize
  expressions of grief                                                      Assume a child is
                                                                            not grieving because
                                                                            of laugher or play
   Think all children
     feel the same
                                                                             Avoid opportunities
                                                                             To allow expression
                                                                             and understanding
             Avoid the                              Stop telling stories     of feelings
         Grieving PROCESS
                                                           Not talk about their own grief, and
                                                           how support, strength is found
  Use cliché's like „God‟s will‟,
  Or „God took her because
  she was so good‟
                                                    Use euphemisms like „he died in his sleep‟,
                                                    „crossed over‟, or „we lost her”

Objective: Acknowledge Needs of Grieving Children
      Talking to Children about Death & Dying

                                                    Children need to feel safe and secure.


                                                      Try not to put up barriers
                                                      that may inhibit their attempts to talk.




  Keep discussions
  developmentally appropriate.




  Be sensitive to their desire to talk when THEY are ready.
Objective: Acknowledge Needs of Grieving Children
  Talking to Children about Death & Dying
                                                              Be ready for “spurts”…
                                                              when a child is ready
                                                              for more information,
                                                              questions will be asked.

Provide brief and simple answers that are appropriate to the
question asked; do not overwhelm with too much information.


Listen and accept feelings….
create an environment within the
family system that makes it okay to
talk; offer permission to feel & be.



                          Offer honest, simple, straightforward explanations.
         Use concrete vocabulary, such as “die”, death, or “dying”.
          Objective: Acknowledge Needs of Grieving Children
                 A Child‟s Tasks of Mourning
    Experiencing the Pain of Grief
    •Provide a time and place to grieve
    •Recognize that the first days are the most chaotic
    •Provide opportunities for expression
    •Anticipate critical times when intensity may be high
    •Expect more difficulty 6-9 months later




Objective: Acknowledge Grief Process
                 A Child‟s Tasks of Mourning

   Accepting the Reality of Loss
   •Acknowledge the loss each time it comes up
   •Encourage to say aloud what is “missing” at that moment
   •Talk about “new reality” in structured manner
   •Stick to facts, what is known, or information learned




Objective: Acknowledge Grief Process
                 A Child‟s Tasks of Mourning
  Adjusting to an environment
  •Talk about how things are different now
  •Encourage to say aloud the things their loved one used to do
  •Brainstorm who can do those things now (not replace, but embrace)
  •Recognize the “empty space”
  •Involve children in problem solving to handle reminders
  •Plan events that honor presence in life and death




Objective: Acknowledge Grief Process
                 A Child‟s Tasks of Mourning
Reinvesting emotional energy
•Resolution of loss is a focus on the meaning of the life, not the death
•Select memorial activities, events that honor the life
•Discover things “in common” that express honor
•Decrease attention on expressions of continual trauma reminders
•Increase attention on expressions of good life lived
•Validate efforts made by the child to embark on “new normal”




                                  Heart Equation
                                  T+T=H
                                   T
Objective: Acknowledge Grief Process
     KEEP IN MIND ~ Children Need
               To feel safe in confusion
              Routine, Order, and Stability
                 Designated Safe Place

                         Comfort
Do not reject their emotions or their efforts to comfort you

                       Permission
     Do not tell them How to feel or How Not to feel
                 Assurance of being okay

                        Patience
         They will ask questions over and over

              Opportunities to say goodbye
    Death is not contagious…be sure to differentiate.
            Children tend to idolize the dead

   Gently help children regain balance and perspective
                              Compassion Fatigue




   May be manifested as anger, anxiety, blame, helplessness, guilt
  May look cynical, or appear as decrease in tolerance or sensitivity
                May feel difficult maintaining hope
      May take the form of a chronic or delayed grief response
                    …no satisfactory conclusion.
                                Professional caregivers are distant mourners
                               Effects of professional grief are hidden & subtle
                                        Professional losses accumulate
                                        Is a significant cause of burnout
Objective: Self Care Skills
                              So What About YOU?
                              PRACTICE SELF-CARE
Be aware of professional boundaries
Maintain Balance with ongoing self monitoring
Learn to express professional grief in appropriate ways

Let others know what you need
                                                         Manage Stress
Treasure relationships                                    Say Goodbye
Draw on support                                    Tend to Basic Health Needs
Be patient with yourself                             Sustain Family Support
                                                      Nurture Friendships
                                                    Relax, Rest, Rejuvenate
                                                              Laugh
                                                      Attend Peer Meetings
                                                       Be Nice to Yourself


         Acknowledge your feelings, grief reactions, and
           experiences of loss as part of your journey
Objective: Self Care Skills
Grief is a Journey
 A little laugh
     A little hope             Nora Gravois, LMSW-IPR
                              Bereavement Coordinator
         A little promise     The Hospice of East Texas
                                   4111 University Blvd.
                                      Tyler, Texas 75701
                            www.hospiceofeasttexas.org
                               (903) 266-3447 direct line
     Resources for Children Coping with Death & Dying

Karaban, Roslyn A. Ph.D: Complicated Losses, Difficult Deaths, 2000
Rando, Therese A, Grief, Dying and Death, 1984.
Schaefer, Dan, Ph.D., & Lyons, Christine: How Do We Tell the Children, 1986
DSMIV-TR

Numerous works of:
Elizabeth Kubler-Ross
Dale Larson
Alan Wolfelt
William Worden

								
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