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C H A P T E R

27Grief and Bereavement in Children

Robin Fiorelli

■ Introduction■ Children’s Concepts of Death and Responses to Grief

Infancy (to Age 2)

Preschool (Age 2–4)

Early Childhood (4–7)

Middle Years (Ages 7–10)

Preadolescent (Ages 10–12)

Adolescent (Ages 13–15)

Adolescent (Ages 15–18)

■ Normal Grief Reactions in ChildrenPhysical Symptoms

Cognitive Symptoms

Emotional Shock and Denial

Sadness, Despair, and Depression

Anger and Acting-Out Behavior

Regressive Behaviors

Fear, Anxiety, and Panic

Guilt, Shame, and Self-Blame

Jealousy

Acceptance

■ Normal Grief Experience for a Teenager■ Complicated Grief Reactions in Children and

Teenagers■ Preparing a Child for the Death of a Loved One

Predeath Support

How to Talk to a Child When the Death Occurs

Typical Questions That Children Have About

Death

■ Guidelines for Helping Bereaved Children ExpressTheir GriefSadness/Depression

Anger

Guilt and Regrets

Fears

Physical Complaints

Bereavement Support Groups for Grieving

Children

Support from Schools for Grieving Children

Play Therapy for Grieving Children

■ Guidelines for Helping Grieving Teens■ Grieving Parents Need to Take Care of Themselves■ Guidelines for Children Attending Funerals and

Memorial ServicesExplaining Burial and Cremation to a Child

Ways to Commemorate the Loss with a

Grieving Child

Holidays and Special Anniversaries

Death of a Parent or Significant Adult

■ Death of a Sibling■ Conclusion

635

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INTRODUCTION

Both mental health practitioners and parentsalike have been misguided about how childrenand teens experience the loss of someone signifi-cant to them and about the most effective ways toassist a grieving child. In a systematic review ofthe prevailing misperceptions, Charles A. Corrlisted most centrally the belief that children donot really grieve because they are too young tounderstand death. The reality is that children’sgrief may look different than that of adults, butit shares fundamental similarities as a physicaland emotional reaction to the loss of a significantloved one.

The most compelling myth is that it is best toprotect a child from death and also from grief. Itis natural for adults to want to protect childrenfrom painful experiences. However fanciful thiswish may be, children will grieve in their ownunique ways and it is imperative that caring adultsdo not dictate or impede that process, instead,allow and even facilitate children’s expression ofgrief.

Another myth is that funerals and memorialservices are not age appropriate and children maybe traumatized by the acute emotional experienceat such an event. As will be discussed, currentresearch suggests that a child should receive in-formation about what the event will be like andthen should be allowed to make up his or herown mind about participating, a decision adultsshould honor.

Another common myth is that children are“naturally resilient” and should just “bounceback” after a loss. This is not always the case anddepends on contingencies such as concurrentstressful events, the child’s understanding of thedeath, the child’s developmental age, and thesupport received by adults in their life. Onthe other hand, John Bolby in his work on attach-ment and loss concluded that children are more

susceptible to profound emotional scarring afterexperiencing a significant loss. Supposing this po-tential exists, its realization still depends on thefactors already listed, most importantly the atti-tudes and behaviors of adults important in theirlives.

Children tend to attribute physical symptomsto emotional experiences more than do adults.Many parents are familiar with the headache thatappears when a child is overwhelmed with emo-tion or with the stomach ache that appears themorning before a school test. There is much de-bate about whether children really experienceemotions more as a physical sensation than doadults or whether they know that adults in theirlives are more apt to heed physical rather thanemotional symptoms.

This chapter begins by outlining children’sconcepts of death and grief responses, differenti-ated by developmental level and chronologic age,through adolescence. The most common phys-ical, emotional, social, and spiritual grief reac-tions of children and teens will be explored indepth, following which, complicated grief reac-tions in children and teens will be outlined. Thechapter then shifts to a discussion on how toprepare a child for the impending death of aloved one, what to tell them when the death ac-tually occurs, and the questions one might ex-pect children to ask during this difficult time.The chapter then turns to the topic of how to as-sist bereaved children and teens in expressing andcoping with their grief as well as where to find ad-ditional sources of support for the grieving childand teen. Suggestions for grieving parents in car-ing for their own grief needs are also included.How children may attend and participate in fu-nerals and memorial services, including guidancefor how to discuss burial and cremation with chil-dren, and how to help grieving children partici-pate in memorial activities, including those onanniversaries or birthdays, are shared. Finally,two of the most significant losses for a child willbe examined closely, that of a parent and that of asibling.

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Chapter 27 ■ Grief and Bereavement in Children 637

CHILDREN’S CONCEPTS OF DEATHAND RESPONSES TO GRIEF

Each child is unique in his or her understandingof death and response to grief. This understand-ing is largely influenced by the child’s develop-mental level and chronologic age. There can betremendous overlap, however, between the agegroups because children and adolescents movefrom one developmental level to another at verydifferent rates.

INFANCY (TO AGE 2)Babies do not have the cognitive capability to un-derstand an abstract concept like death. Theyfunction very much in the present, so when some-one significant dies, babies become more acutelyaware of loss and separation. They also react tothe emotions and behaviors of significant adultsin their environment and also to any disruptionsin their nurturing routine and schedule. If there isa sudden change, they feel tremendous discom-fort.

Therefore, in response to a loss, babies maysearch for the deceased and become anxious asa result of the separation. Common reactions in-clude: irritability and protest, constant crying, achange in sleeping and eating habits, decreasedactivity, and weight loss.

PRESCHOOL (AGE 2–4)When will my mommy be home?

How does (the deceased) eat or breathe?

Preschool children do not comprehend theconcept of “forever.” For this age group, deathis seen as temporary and reversible. Even whena preschooler is told that mommy is not coming

back, for example, she or he may ask the samequestion again an hour later. These children of-ten have difficulty visualizing death as separatefrom life, and not as something that can happento them. Preschool children love to play “peek-a-boo” games where adults in their life disap-pear and then reappear again. It is through thesegames that they slowly begin to understand theconcept of “gone for good.”

Because preschoolers tend to be present-oriented, their grief reactions are brief althoughoften very intense. As these children are goingthrough the developmental stage where they arelearning to trust and form basic attachments,when a significant adult in their life dies, theybecome very concerned about separation and al-tered patterns of care. Children this age typicallyhave a heightened sense of anxiety concerningseparations and rejections because they do nothave the capacity yet to use fantasy to gain con-trol over what is happening.

They also respond to the emotional reactionsof adults in their life. If they sense their parents areworried or sad, they may cry or throw tantrumseither because they are concerned or as a way todistract their parents from difficult emotions.Typical grief responses of the preschool child in-clude confusion, frightening dreams and nightagitation, and regressive behaviors such as cling-ing, bedwetting, thumb sucking, inconsolablecrying, temper tantrums, and even withdrawalfrom others. They may search intensely for thedeceased despite assurance they will not return.They also may exhibit anxiety toward strangers.

EARLY CHILDHOOD (4–7)

It’s my fault. I was mad at my mother once and I

told her I wish she would die and then she died.

The roadrunner in the cartoon always comes back

to life, so I know Daddy will too

As with preschoolers, children in the 4 to7 age group tend to view death as temporary and

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reversible. They sometimes feel responsible forthe death because they believe that negativethoughts or feelings they have had about the de-ceased caused their demise. This “magical think-ing” stems from the belief that everything in theirenvironment revolves around them and that theycan control what happens. Even when children atthis age are exposed to death through the mediaor at school, they still may believe that if you arecareful enough you can avoid death.

Children at this age may also connect occur-rences that do not have anything to do with eachother. For example, if a child bought a certain toythe day that her sister died, she may attribute thetoy to causing the sister’s death, especially if thereal cause of the death is not fully explained toher.

Not surprisingly, therefore, children of thisage group, much like their younger counterparts,may repeatedly search for the deceased or askwhere they are. Repetitive questioning about thedeath process, such as “What happens when youdie?” “How do dead people eat?” is often com-mon. They will often express their grief feelingsthrough play instead of verbally. Themes of familyloss and death may surface as they play with dollsor action figures. They may play act the deathitself or the funeral.

Sometimes, children at this age appear un-affected by the death and act as if nothinghappened, but this doesn’t mean that they areoblivious or that they have accepted the death.It may just signify their inability in the momentto acknowledge very painful reality. They alsomay model their grief reaction after the adults intheir lives, feeling uncertain how to express grieffeelings. Other typical responses include anger,sadness, confusion, and difficulty eating andsleeping.

As with preschoolers, this age group mayregress as a way to receive more nurturance andattention during this difficult time. Children whohave experienced a loss at this age tend to be fear-ful that other loved ones will leave them as well.Sometimes they form attachments to people whoresemble the deceased in some way.

MIDDLE YEARS (AGES 7–10)

Do your fingernails and hair keep growing when you

die?

If I smoked cigarettes, would I die?

Although children between the ages of 7 and10 often still want to see death as reversible, theybegin to see it as both final and universal. Chil-dren in this age group sometimes visualize deathin the form of a tangible being such as a ghostor boogeyman. They are very curious about thedetails of death, cremation, and burial and mayask candid questions

Even though they know death can happento anyone and that there are many things thatcause death, they still do not typically think ofdeath as something that can happen to themor their family members, instead, to only oldor very sick people. They may believe that theycan escape from death through their own ef-forts. They also might view death as a punish-ment, particularly before age 9. Sometimes theyare unable to comprehend how the death will af-fect their lives, which can become a source ofanxiety.

Children in the middle years often becomeconcerned with how others are responding to thedeath as they become less focused on themselvesand more on others. They may fear that otherloved ones will die as well. Sometimes they maybecome overly concerned about their own healthand may fear bodily harm and death.

Some children in this age group may act outtheir anger and sadness and experience difficul-ties in school due to a lack of concentration. Onthe other hand, they may have a jocular attitudeabout the death, appearing indifferent, or theymay withdraw and hide their feelings. Other typ-ical responses include shock, denial, depression,changes in eating and sleeping patterns, and re-gression to an earlier developmental stage.

This age group tends to have more copingstrategies available than younger children andmay fantasize how they would prevent the deathfrom happening again as a way to gain control

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Chapter 27 ■ Grief and Bereavement in Children 639

over the situation. Death is also play-acted in chil-dren at this age, for example, through war games,especially for those children who have difficultyexpressing feelings verbally.

Children in this age group may assume the roleof the deceased in the family or the mannerismsof the deceased. They may also take on tasks orchores normally performed by the deceased, suchas care for their siblings. They may idealize thedeceased as a way of maintaining a bond withthem.

PREADOLESCENT (AGES 10–12)None of my friends could ever relate to what it’s like

losing their Dad.

While I know that Grandma is not coming back and

I will miss her, I don’t understand why my Mom is

so upset about it

Preadolescents conceive of death in much thesame way as children in the middle years witha few additions. Preadolescents are in the pro-cess of establishing their own identity, increasingtheir independence from their parents and otheradults and increasing their dependence on theirpeer group. In understanding death, preadoles-cents attempt to understand both the biologic andemotional process of death. They are, however,more able to understand the facts surroundingthe death of someone than they are the feelingssurrounding the death.

It is common for preadolescents to want tocover up their feelings about their loss so as notto appear “different” from their peer group. Theyfear that expressing sad feelings may be seen as asign of weakness (particularly for boys). For thisreason, they may appear removed and indiffer-ent. Preadolescents may also express their grieffeelings in uncharacteristic ways such as throughanger outbursts, irritability, and bullying behav-ior. Feelings may also be exhibited through phys-ical complaints, moodiness, changes in sleepingand eating patterns, indifference toward school-work, or isolation from their peers. They may

show concern for practical issues after the deathsuch as how the household will survive with-out the deceased or how they personally will betaken care of. They also might have questions re-garding religious and cultural beliefs related todeath.

ADOLESCENT (AGES 13–15)These years are often marked by stressful phys-ical changes. Boys are usually a little slower tomature than girls in this age range, but the stressof change is ever-present—from radical growthspurts to facial skin problems. Teens in this agerange are seeking to establish their unique iden-tity, often separate from parents and family. Theyare beginning to think about spiritual and philo-sophical ideas for the first time in truly abstractways. And, they generally experience powerfuland deep emotions that they may feel no one canunderstand.

One of the difficult tasks a grieving teenagerfaces is integrating loss into his or her currentemotional life. This integration can be com-pounded by physical and hormonal changes.Grief may be expressed by frequent headachesor stomach aches, or through feeling sad and de-pressed. Another common reaction is for middleteens to manifest their grief in mood swings andoutbursts of anger. Some teens withdraw to a safeplace, such as a bedroom, where the anger maybe acted out by pounding on a wall or beating apillow. Some may act out the anger through inap-propriate social behavior, pouting, or aggressiontoward others. Grades may decline in part dueto sleep disturbances, which are often combinedwith depression and a general feeling of meaning-lessness.

It is not unusual for middle teens, both girlsand boys, to want a special “friend,” such asa teddy bear to hug and sleep with during thistime. It may be important for a caregiver to pro-tect this information from other family membersand friends, especially in the case of a boy. Theteenager also may want to wear a special article

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of clothing that belonged to the deceased. He orshe may adopt certain mannerisms or behaviorsassociated with the deceased loved one, or ide-alize his or her relationship with the deceased.Being tolerant of what may be seen as “childish”or immature behavior allows middle teenagers toprocess the loss in their own, personal and im-portant ways.

ADOLESCENT (AGES 15–18)Adolescents in the 15 to 18-year-old age groupare in the process of becoming young adults.They want to be treated with respect and col-legiality. Providing assistance to grieving ado-lescents, therefore, can be complicated by thefact that although they may be young adults,they do not have the full experience of adult-hood. They are also in the process of differentiat-ing and distancing themselves from the parentalfigures in their lives. The peer group is theirmajor authority—and how they are seen andjudged by their peers is of primary importance tothem.

These older teens often become sullen andnoncommunicative. Their anger may be ex-pressed through exaggerated conflict with paren-tal figures, pushing hard to overturn formerlyunderstood limits. They may become insecureabout the future, question the meaning of life,and question or abandon the family’s belief sys-tem. They may have sleep problems, such asrecurrent or disturbing dreams and insomnia.Sometimes they regress and become immatureand childish, or they mask their fears with jokesand sarcastic remarks.

Sometimes, older adolescents who suffer a lossmay idealize the deceased loved one. They mayadopt mannerisms, habits, and preferences of thedeceased. They may want to wear certain itemsof clothing, especially a hat, shirt, or jacket thatbelonged to their special loved one. Or they mayreact by feeling abandoned and angry at unful-filled expectations in their relationship with thedeceased.

NORMAL GRIEF REACTIONSIN CHILDREN

We now examine more in detail the typical andnormal grief reactions that children and adoles-cents experience during the grief process. Somegrief reactions with children occur immediatelyand others may occur at a later point. In general,children’s grief tends to manifest in physical andbehavioral expression rather than verbal expres-sion.

In addition to developmental level and chrono-logic age, the main factors that influence how achild grieves are the relationship with the per-son that has died, the nature of the death (when,how, and where the person died), the child’s ownpersonality, previous experiences with death, re-ligious, and cultural beliefs, input from the me-dia, and above all, what they are taught aboutdeath and grief from adults and the availabilityof family, social, and community support. Themore common physical, cognitive, and behavioralreactions that may occur to children during thenormal grief process are listed in Table 27–1 andare discussed below.

PHYSICAL SYMPTOMSI don’t feel good. I feel sick to my stomach.

Last night I dreamed that Johnny came back to visit

me. He was all grown up, though, and he had a

mean look and wanted to hurt me.

Chief somatic complaints of a grieving childinclude headaches, stomach aches, fatigue, lackof energy, muscle aches, tightness in the throat,difficulty breathing (especially when they firstlearn about the death), skin rashes, changein eating patterns (lack of appetite or exces-sive appetite), change in sleeping patterns (bothfalling asleep, staying asleep, and sometimes pro-longed sleeping), odd and frightening dreams,hyperactivity and hypersensitivity (especially if

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Chapter 27 ■ Grief and Bereavement in Children 641

TABLE 27–1. Normal Grief Reactions in Children

REACTION EXAMPLES

Physical symptoms HeadacheStomach acheFatigueLack of energy

Muscle achesThroat tightnessSkin rashesHyperactivityHypersensitivity

Changes in eating habitsDifficulty breathingChanges in sleep habitsOdd and frightening dreams

Cognitive symptoms Inability to concentrateObsessed with or preoccupied with deceasedPreoccupation with the death, or the meaning of deathCarrying objects owned by the deceasedRepetitively looking at photos of the deceasedVisual hallucinations of the deceasedAdopting deceased’s roles or physical mannerisms

Behavioral changes Emotional shock Anger and acting outDenial Regressive behaviorSadness, despair Fear, anxiety, panicDepression JealousyGuilt, shame, self-blame Acceptance

the loss was traumatic). Most of these physicalsymptoms are temporary and go away with timewhen the child begins to receive adequate griefsupport. Some children develop physical symp-toms that resemble the symptoms of the illnessthat they observed in the deceased. This may bea child’s attempt to stay connected in some waywith the deceased or a way to express his or herown fear about getting sick. When children re-ceive a great deal of attention for their physicalsymptoms, they may exaggerate the “sick role”as a means to obtain socially acceptable attentionfor their grief feelings.

COGNITIVE SYMPTOMS

I couldn’t focus on my school work today. I don’t

remember one thing that I learned.

My Dad was the best father in the world. He never

even once got mad at me

When I went to sleep last night, my Mom came and

sat in the chair by my bed.

Many bereaved children describe an inabilityto concentrate for any length of time after a sig-nificant loss. Their thoughts seem to be taken upwith the death and loss of their loved one. RabbiEarl A. Grollman discusses how children idealizethe deceased as a way of coping with their loss.In an attempt to counter unhappy thoughts, thechild may become obsessed with only the posi-tive qualities of the deceased. Some older chil-dren become preoccupied with “why” the deathhappened, may want to know all the facts sur-rounding the death, and may search for the“meaning” of the death. Some children searchfor their lost loved ones with the hope of find-ing them. They may seek out places they used togo together. Other children become temporarilypreoccupied with memories of the deceased, ask-ing other adults to tell stories about the deceasedover and over again, carrying objects of the de-ceased around with them, and looking at photosrepetitively.

Visual hallucinations of the deceased are alsocommon and are experienced as very real to the

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child. Sometimes they can be comforting andother times terrifying. Identification with the de-ceased by incorporating mannerisms or taking onthe deceased’s roles such as disciplining the otherchildren are also common. All these behaviorsare an attempt by the bereaved child to recon-nect and relate to his or her deceased loved one.They should all be viewed as a normal part of thegrief process unless they persist unnaturally longor cause a great deal of distress for the child.

EMOTIONAL SHOCK AND DENIAL

I don’t believe you. My mother will come back. You

are wrong.

Even though it’s a year later, I still can’t believe that

Grandma is gone.

Usually, when the realization of the death is toooverwhelming, the child temporarily denies that ithappened. Denial of the death is not unusual, butit can be difficult for adults to endure. It shouldbe viewed as a protective mechanism; a way forthe child to comprehend painful information atthe speed with which they are ready. Denial ismost common in the first few months followingthe death, but may reappear at different timesthroughout the grief process.

SADNESS, DESPAIR, AND DEPRESSIONI don’t want to live without my Dad.

I miss my Mommy and I want her back.

There are many different ways that childrenexhibit feelings of sadness and despair followinga loss. They may express it verbally, nonverballythrough a depressed demeanor, through tears,or by becoming withdrawn, isolated, and quiet.Children sometimes react in total despair and areinconsolable when they first learn the news of thedeath. The full realization of the loss does nothappen all at once, but as it does, sadness, lone-liness, and depression can follow.

ANGER AND ACTING-OUT BEHAVIORI hate you and wish you had died instead of Dad.

I hate school. I hate my friends. I hate my family. I

hate my life. I hate everything.

It is often easier for children to feel mad, thento feel sad and children typically strike out withanger at the people with whom they feel closestand most safe. There are many reasons why griev-ing children feel angry. They may feel angry at theperson who died for leaving them, angry at God,at others in their family, and at the doctor for notdoing more to save their loved one. They maybe angry at themselves because they believe theycaused the death (magical thinking) or that theydid not do enough to prevent the death. Angeroften originates from feelings of helplessness andlack of control.

There are some bereaved children that channeltheir anger by defying authority, rebelling againsteverything and by displaying somewhat antiso-cial tendencies. Antisocial behavior in a bereavedchild is often an attempt to keep themselves awayfrom any close relationships and the possibilityof being “abandoned” again. It is important tonote that anger expression generally is more so-cially acceptable among boys than girls. Youngerchildren are often more physically expressive anddirect when they are angry. They throw things, hitand kick, and have tantrums. Anger outbursts areoften set off by seemingly unimportant triggers inbereaved children.

REGRESSIVE BEHAVIORSIt is very common for bereaved children toregress in some way to an earlier developmen-tal or chronologic age. Death of a loved one cancause complete disruption in their routine and intheir sense of safety, and regression to a time intheir life where they felt more secure and famil-iar should be seen as a healthy adaptation to atraumatic situation. Usually, regressive behaviorsare temporary and subside with time as the child

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Chapter 27 ■ Grief and Bereavement in Children 643

receives appropriate grief support. It is importantthat adults in a grieving child’s life find a balancebetween allowing the regression and gently ex-pecting the child to return to his or her formerlevel of functioning.

Examples of regressive behaviors includebedwetting and thumb sucking, difficulty sep-arating from significant others, demanding at-tention, regressing from prior advances towardindependence, difficulty with developmentallyappropriate tasks, needing to sleep in parent’sbed, needing to be held or rocked, reverting tofantasies of an earlier age, talking in baby lan-guage, giggling inappropriately, and inability tofunction with peers.

FEAR, ANXIETY, AND PANIC

Are you going to die when you go to sleep tonight

like Grandma did?

Who is going to take me to school now that Daddy

died?

I think I’m going to get cancer too.

Children often react with fear and panic whenthey lose someone significant to them and maybe afraid of the intensity of their own feelings.They become concerned about how other griev-ing adults will fare. They worry as well aboutthe changes in care-giving and nurturance thatcome with the loss. Some grieving children be-come concerned that someone else close to themwill die and that they will have to feel that painagain. In some cases, these children withdrawfrom other important adults so as not to repeatthe hurt.

Bereaved children often feel afraid of becom-ing sick or of dying themselves. They may becomeafraid of the dark, of sleeping alone and of beingseparated from or abandoned by other significantadults. Unfortunately, this is especially true if aparent has died and the other parent is somewhatdetached from the child because of the parent’sown grief reaction.

GUILT, SHAME, AND SELF-BLAMEIt’s all my fault that Janey died. I told her I wished

she was dead when she broke my doll and now she

is dead.

I never liked my brother. He always teased me. Now

I feel so guilty because he died.

Bereaved children sometimes believe they areresponsible for the death, especially if they hadever wished the deceased dead. Some childrenfeel guilty if they experience relief that the personhas died, even though this is very normal reaction,especially if their loved one had been suffering.Other children feel guilty because they had a dif-ficult relationship with the deceased. Frequentlyinterrelated to self-blame is a sense of helpless-ness and worthlessness. If grieving children feelhelpless, they may try to gain some control bythinking what they would have done differentlyto change the situation.

JEALOUSYI can’t go to the Father/Daughter dance because I

don’t have a father.

I hate when all the kids at school talk badly about

their parents. They should feel lucky they HAVE

parents.

It is very common for bereaved children to feellike they have been short-changed in some way,especially if the loss is that of a parent. It be-comes particularly difficult for them during hol-idays such as Mother’s or Father’s Day, at theirbirthdays or graduations, and when they receiveawards, because all these events serve as continualreminders to them of their loss. Feeling jealousthat other children have parents is very common.

ACCEPTANCEWhen Dad first died I thought my life was over.

Now I feel like I’m starting to look forward to things

again.

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J. William Worden, a leading expert in griefand loss, describes the process by which a childbegins to accept a significant loss. Acceptance ofthe loss comes gradually as does the understand-ing that the death is final. Most children describea kind of “new normal” as they begin to adjustto the loss. They still think about their loved onethat died and understand that their life has beenchanged, but they begin to reconstruct a life with-out their loved one in it. In the case of the death ofa parent, they begin to feel secure that they will betaken care of and will have their needs met. Theyrealize there are other significant adults availablefor support. Older children sometime state thatgoing through a grief experience allowed then tolearn to feel more compassion toward others andmore tolerance for other problems and challengesin their own lives.

Alan Wolfelt, another leading expert on chil-dren’s grief, calls the healing process that griev-ing children go through “reconciliation.” He saysthat reconciliation happens when a whole andhealthy person emerges from grief. The personrecognizes that life will be different without thepresence of the significant person who has died.Reconciliation is a process not an event, and itdoes not occur all at once—it is a slow, painfulprocess. The most notable changes during thechild’s “reconciliation” process include a returnto stable eating and sleeping patterns, a renewed

sense of energy and well-being, a subjective senseof release from the person who has died, in-creased thinking and judgment capabilities, thecapacity to enjoy life experiences, a recognitionof the reality and finality of the death, and theestablishment of new and healthy relationships.

NORMAL GRIEF EXPERIENCEFOR A TEENAGER

By the end of high school, 20% of today’s stu-dents will have lost one of their parents; 90% willhave experienced the death of a close relative orloved one. Add to this that 1 in every 1,500 sec-ondary school students dies each year, and we cansee that death and the resulting grief followingdeath is a part of everyday life for many teenagers.Recognizing and providing constructive ways forteenagers to express their grief will help preventprolonged or unresolved grief and depression.

Grief is as unique as the people who experienceit, but there are some reactions to grief that we allfeel and that are considered normal or typical griefreactions. For teens who experience the death ofa loved one, these typical grief reactions, listedin Table 27–2, often resemble those described

TABLE 27–2. Normal Grief Experiences for Teenagers

Assuming mannerisms, traits, or wearing clothes of the deceased.Emotional regression and even bed-wetting, which can be most upsetting for teenagers.Needing to repeat again and again stories of their loved oneSaying nothing at allBecoming overly responsible (the “new” man or woman of the house), which distracts

them from their own feelings by taking care of everyone else.The need to integrate the loss into their budding identityAnger and lashing out at others that can happen at any time for no real reasonIntense anger at the deceased for dying, and later feelings of guilt for being angry.Mood changes over the slightest things; unexpected outbursts or crying.A feeling that the loss is not real and did not happen at all

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earlier for children, albeit in a somewhat olderage context.

Teenagers experience their loss at differenttimes in their development and the first and sec-ond year may be the most difficult. Part of nor-mal development for a teenager is to reintegratewhat they have learned about their loss into theircurrent developmental stage. Special days andimportant times may serve as reminders of theirabsent loved one. The process of integrating theloss may resurface on these special days. Forexample, a high school senior wore his deceasedfather’s shirt to his graduation exercises. A 19-year-old bride proposed her first toast to her de-ceased grandmother, a most significant figure inher life.

COMPLICATED GRIEF REACTIONSIN CHILDREN AND TEENAGERS

Prior to her mother’s death from liver cancer, Sarah

had been doing well in school, was captain of the

gymnastic team and had several close friends. As

Sarah and her Mom were very close, it was expected

that Sarah would have a difficult time adjusting to

her Mom’s death, although everyone remarked how

“well” Sarah was coping as her mother was dying.

Her father explained, “She seemed to hold it all

together so well.” Even after the death, Sarah re-

turned to school and to her normal routine fairly

quickly. “Then all at once everything started to

fall apart. It was as if she finally understood that

her mother was really gone.” Sarah started missing

school and her grades began to slip. She lost inter-

est in gymnastics and quit the gymnastic team. She

had trouble getting out of bed and began saying that

she wished she were dead. She rejected her peers’

attempts at helping her and stopped answering the

phone. Her Dad noticed that she stopped caring

about her appearance and that she even looked di-

sheveled. At first, her Dad was patient and thought

it would pass. He was so involved in his own mourn-

ing that he didn’t seem to notice just how serious her

depression had become. He finally called the school

counselor who referred him to a grief specialist who

worked with children. Sarah was reluctant at first,

not believing that anything would help. Finally, she

agreed to go, began to express her anger and sad-

ness, and over the course of several months began

to resume her normal activities and functioning.

Thus far, the emotional, physical, and behav-ioral grief responses that have been described arenormal expressions of grief in children and ado-lescents. A child may experience some or all ofthese reactions or may show no overt reactionat all. However, if any of these typical responsesto grief are prolonged, extreme, pervasive,affecting the child’s ability to function nor-mally in school or with their peers, or in provid-ing self-care, like in the case with Sarah, the griefwould now be considered “complicated.” Exam-ples of complicated grief reactions are listed inTable 27–3. When a bereaved child exhibits anyof these behaviors, immediate professional ad-vice and assistance should be sought. There aremany community sources that provide supportfor grieving children including school guidancecounselors, pediatricians, clergy, mental healthpractitioners, and hospice bereavement person-nel. Further discussion of how to manage com-plicated grief reactions in children and teenagerscan be found below.

PREPARING A CHILD FOR THEDEATH OF A LOVED ONE

PREDEATH SUPPORTIf an adult can prepare a child or teen for the deathof a loved one, it is important to do so as soon aspossible before the death occurs. First, asking achild what he or she knows about a loved one’sillness allows the adult to discover any misper-ceptions that the child may have, and assists theadult in knowing where to start from in educating

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TABLE 27–3. Complicated Grief Reactions in Children and Teenagers

BEHAVIOR EXAMPLES

Suicidal thoughts and behaviors “I just want to kill myself”Giving away valued possessionsPreoccupation with suicidal themes in mediaDesire to be with deceased loved oneSelf-punishment ideation or behaviors

Prolonged sleep disturbances InsomniaNightmares

Persistent personality changes Neat, well-groomed child abandons bathing,grooming, and dressing habits

Eating habits change: too much or too littleExtrovert turns into introvertOptimist becomes pessimistPleasant child becomes a bullySecure child becomes anxious and afraid

Aggressive behavior Dangerous risk-taking behaviorsBehavior dangerous to others

Excessive or inappropriate guilt Child ruminates how she or he caused death ofloved one

Extreme fatigue or loss of energyon a prolonged daily basis

Inability to get out of bed that lasts more than10 d

Extreme withdrawal or isolation Inability to socialize with othersDespairDepressed affect

Pervasive fantasies thatinterfere with normalfunctioning

Belief that loved one will return, especially if she orhe is good

Phobias that interfere withfunctioning

Fear of getting sickFear of dyingAvoiding anything having to do with death

Hypervigilance Checking on other parent constantlyChecking themselves and others for symptoms

that mirror those experienced by the deceasedHyperalertness in a car if loved one died in a car

accidentPersistent assumption of

mannerisms of the deceasedAssumption of chores and responsibilities of

deceased that are not developmentallyappropriate

Preoccupation with the deceased to the point that it interferes with normal function

Drug and/or alcohol use

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the child about the illness and prognosis. It is im-perative that the adult presents the informationin a gentle and calm manner, allowing the childto voice questions and concerns. Children canusually absorb only a little information at a time.

It is important to look for “teachablemoments”—moments when the child seemsopen to learning. It should be explained that allliving things must die. The adult could show thechild plants and insects that have died and tellthem that because people are living things, theydie too. Explain that the changing seasons are an-other example of the cycle of life and death. Thechild should be told that the images they see ofdeath in television cartoons are not always au-thentic and that death is irreversible. The adultcan explain to the child that people usually live along life, but that sometimes when someone de-velops a very serious illness, he or she dies beforebecoming old. The adult can also explain thatdoctors usually help people live long healthy lives,but that sometimes even doctors cannot stopsome people’s bodies from malfunctioning. Usingseveral adjectives like “very, very sick” or “very,very old” helps the child distinguish betweensomeone with a common cold versus someonewith a terminal illness and between their parents,who may seem old to them, and elderly people.The child should be reassured that this is not apunishment, or God’s fault or anyone’s fault, butthat sometimes it just happens. She or he can alsobe reassured that death is usually not painful andthat it is almost always quiet.

When a loved one is dying, if a child is oldenough to understand what is happening andboth the child and the dying person would liketo see each other, the child should be allowedto visit the loved one. The child should be pre-pared beforehand about what she or he mightsee or hear and what feelings might be experi-enced. The child should be told what the lovedone might look like, and the setting, includingmedical equipment if applicable, should be de-scribed. Depending on the age of the child, it maybe advisable to keep the visit short. Visiting witha dying loved one might be a way for a child to

understand the reality of the death, and a way forimportant communication to take place betweenthe child and the loved one. The key is that thevisit must be the child’s choice. If the child doesnot want to visit, a supportive adult should at-tempt to elicit why the child is resistant, but thechild’s wishes should be honored.

Throughout the illness, a child should be toldabout changes in a loved one’s condition as theyarise. A child should be allowed to care for a lovedone in a way that he or she chooses, be it throughwriting cards or bringing a glass of water or tis-sues. Sometimes, caring for a dying loved one al-lows a child to feel less helpless.

HOW TO TALK TO A CHILD WHEN THEDEATH OCCURSIdeally, a child or teen should be told in a gentleand caring way about the death as soon as it oc-curs, by someone they trust and feel close to. Itmight be helpful to prepare the child for the newsby saying, “I’m afraid I have some bad news.”The explanation should be kept simple, avoid-ing euphemisms such as, “passed away,” “ex-pired,” “went away,” or “went to sleep.” Theseeuphemisms may cause the child to believe theperson will come back or wake up, or conversely,may cause the child to be afraid to go to sleep atnight. A suggested approach might be, “Daddyhas died. He was very, very sick. Daddy had a dis-ease that made him very weak and he was not ableto get better. Daddy is now unable to move, feel,talk, eat, or hurt anymore.” By being direct, thechild’s confusion and fantasies about what hap-pened are usually diminished.

When a child is told about the death of a lovedone, she or he needs to be allowed a lot of timefor expressing reactions and feelings, as well asfor raising questions and concerns. By sharingtheir own feelings with a child, adults can helpnormalize what the child might be feeling. Thechild should also be made aware of what othersin their environment may be feeling and thinkingand should be reminded that sadness, anger, and

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fear are all normal feelings when someone dies.It is also important that the child is told what fu-neral arrangements or rituals will happen next, sothey know what to expect. They should be reas-sured by being told specifically what will happento them and how they will be taken care of.

TYPICAL QUESTIONS THAT CHILDRENHAVE ABOUT DEATHIt is important that the questions posed by chil-dren and adolescents are answered in a specific,straightforward, and brief fashion, and reflect thedevelopmental level of the child. Children canusually absorb only bits of information at a timeso it is important to pay attention to their cues.Checking to see if a child has understood whathas been said is also critical. Adults unsure of themeaning behind a child’s question should probefurther by asking what the child meant or knowsabout the topic. Children often repeat the samequestions merely as a way to assimilate the an-swers. It is also okay for adults to tell the childthey do not know the answer to a specific ques-tion.

Some of the most common questions childrenask are the following:

Why did daddy die?: It is important to probefurther to assess whether they are askingthis question because they feel sad, angry, orguilty about the death. If so, it is imperativeto allow the child to express those thoughtsand feelings. The child should be reassuredthat death does not seem fair. It may alsobe that they are asking about the physicalprocess of death.

When is mommy coming back?: It is okay to tell achild in a gentle loving way that people whodie do not come back; that as much as sheor he may want mommy to come back, shecan’t because she is dead. Sometimes, it isreassuring for a child to know that she or hecan always hold onto feelings and memoriesabout a loved one and that in that way, the

loved one will always be with him or her. Itmay also be reassuring for a child to knowthat the feelings of sadness that he or she isexperiencing about a loved one being gonewill go away over time.

Where is daddy now?: Before answering thisquestion, it is helpful to know where thechild thinks daddy is. The adult’s responsewould then be based on that belief. Ifthe child believes daddy is in heaven, be-cause that is the family’s spiritual belief,than that belief should be validated. Also,to minimize confusion, it might be helpfulto remind the child about the burial, for ex-ample, that the loved one was placed in acasket underground.

Will you die too?: It is important when answer-ing this question to give reassurance andsupport and also to answer honestly. An ex-ample would be: “I will die sometime but Ihope to be here a long time yet. I do not haveany serious illnesses.” Sometimes when achild asks this question, she or he is afraid oflosing another loved one. A clarifying ques-tion might be,” Are you worried that I won’tbe here to care for you?”

How long will I live?: A response might be thatno one knows how long they will live, butthat no one lives forever. The child shouldbe reassured that most people live until theyare old and that many old people are notworried about death.

GUIDELINES FOR HELPINGBEREAVED CHILDREN

EXPRESS THEIR GRIEF

A hundred years ago death was much more a nat-ural part of a child’s experience. Grandparentsoften lived with families, so children witnessedthem growing older and dying. Modern medicine

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has made strides in reducing infant and childmortality and has prolonged life expectancy forthe elderly, so children witness fewer deaths.More and more elderly die in nursing homes andhospitals, outside the home environment. The ex-clusion of death from children’s lives requires usto teach them explicitly about death and grief.

In Mourning and Melancholia, Sigmund Freudoutlined his belief that young children did nothave the capacity to mourn. He believed that onlyas a child developed into an adolescent did theyacquire the ego capacity to grieve. More contem-porary research has concluded that children doin fact have the capacity to experience and ex-press grief, but it is often more intermittent anddrawn out over a longer period of time than withadult grief. General guidelines for helping chil-dren express their grief are presented in Table27–4, whereas guidelines that address some ofthe most common specific feelings that childrenexperience are listed in Table 27–5.

TABLE 27–4. General Guidelines for

Helping Grieving Children

Express Grief

Allow children to express grief in their own ways.Do not pressure children to resume normal

activities before they are ready.Allow children to feel that it is OK to talk about

death and grief.Be available to listen.Let children know that having and expressing

feelings are normal.Avoid expressions that suppress grief.Gently intervene if the child is taking on the role

of a bereaved adult.Grieving adults should not hide feelings from

children.Allow children to express religious and spiritual

concerns.Allow children to remain in familiar

surroundings. Avoid sending children away.

The grieving process helps people heal fromtheir pain. Pain is a natural reaction when we losesomeone close and children are capable of accept-ing pain of loss directly and openly. When adultstry to protect children from such pain, they areusually, in reality, trying to protect themselves.The most important thing to remember in help-ing children cope with the death of a loved one isto allow them to express their grief in their ownway and in their own time. It is important not topressure children to resume their normal activi-ties if they are not ready.

Children tend to have “grief bursts” followedby play and normal activities. Children may notbe able to succinctly verbalize what they are feel-ing and instead may demonstrate their feelingsthrough their behavior and play. They may laughor play at a time that feels inappropriate to anadult.

Children need to feel that it is okay to talkabout death and grief. However, if a child doesnot want to talk about grief, adults also need torespect that desire. Adults should let the griev-ing child know that they are available to listenand help and that any feelings they have, such asanger, sadness, fear or regret, are normal. Hug-ging and touching helps the grieving child feelsecure in expressing emotions and also reassuresthe child that he or she is loved and will be caredfor. Alan Wolfelt feels that if grieving children areignored, they may suffer more from the sense ofisolation that from the loss itself.

Messages relayed to a grieving child such as“Don’t cry. You need to be strong,” “You’re theman in the family now,” or “Be a good girl. Yourmommy needs your help now more than ever,”suppress grief expression in children and set upunfair expectations of them. Adults should gen-tly intervene if they observe a child taking on theroles and tasks of a bereaved adult. Grieving chil-dren should not be allowed to take on the role ofthe “confidante” or partner of one parent if theother has died.

It is important that adults not hide theirown feelings of grief from a bereaved child. Ifthey do, they teach them that experiencing these

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TABLE 27–5. Guidelines for Managing Specific Expressions of Grief

EXPRESSION SUGGESTED ACTIONS

Sadness/depression Draw memories of the deceased and show to othersShow photographs and describe keepsakes to othersDevelop a memory scrapbookEngage in physical activity

Anger Allow child to dissipate anger with various activitiesAsk children about their angerAsk the child to suggest ways of responding to angerMaintain household rules and chores

Guilt and regret Write a letter or draw a picture describing “unfinished business”with the deceased

Write a note about feelings of guilt and tie it to a helium balloonin order to “let it go”

Create puppets so that child puppet can talk to puppet of thedeceased

Fear Help child identify fearsProvide repetitive reassurance that all will be OKSpend time alone with child and reassure that s/he is special and

lovedPhysical complaints Ask about other possible feelings, symptoms, or emotions

Remind the child why the death occurredPediatrician visit to reassure child

feelings are not okay, that they are something tobe ashamed of or to be kept to oneself. It is alsotrue that grieving adults should not grieve pro-fusely and at length in front of a child as it mightfrighten and worry the child.

Religion is an important source of strength formany adults and children during the grief pro-cess. Children takes things literally, so explana-tions such as “It is God’s will” or “Bonnie ishappy in heaven” could be frightening or confus-ing rather than comforting, particularly if religionhas not played an important role in the child’s life.It’s important to inquire how the child perceiveswhat is explained about the death. It is also im-portant that children be allowed to express theirreligious and spiritual concerns.

Parents may be tempted to “send childrenaway” when there is a loss—either to protect them

from painful feelings or because it is difficult tocare for them while grieving themselves. Duringthe grieving period, children are often most com-forted by familiar surroundings and routines, andseparation may increase their fears about aban-donment.

SADNESS/DEPRESSIONGrieving children that are sad or depressed re-quire a lot of support and attention so that theycan express their sad feelings and work themthrough. Helen Fitzgerald, a well-known chil-dren’s grief therapist, recommends several tech-niques for helping a depressed grieving child. Shesuggests having the child draw good and badmemories of the deceased and share them with

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others. The child could also could show pho-tographs and describe keepsakes to others anddevelop a memory scrapbook. For a child thatfeels so despaired about a loss, it might be help-ful to ask the child to fantasize how life might bedifferent if she or he was not so sad. Encouragingthe child to engage in physical activity is anotheruseful technique with a depressed child.

Johnny was very withdrawn and depressed for sev-

eral months after the death of his mother. Finally,

his grief counselor suggested he make a “God box”

where he could write down all his sad feelings and

put them in the box and God would help him

feel better. He wrote a new note almost every day

and soon his father noticed that he seemed more

cheerful.

ANGERIt is sometimes easier for a child to feel mad ratherthan sad or guilty. Anger is not always rational andit can escalate by feeding upon itself. Anger doesneed to be expressed, however, and adults canbe helpful in teaching grieving children how toexpress anger in constructive ways. Unexpressedanger can turn into depression or into anger thatis out of control.

Children generally tend to express their angerphysiologically. Instead of asking an angry childto “calm down” it may be more useful to allowthem to dissipate their anger in other ways suchas running, exercising, scribbling on paper, rip-ping paper, singing, and sculpting play dough.It is important to not try to deal with the causeof anger until the intensity has decreased. Adultscan ask children questions about their anger at atime when they are not angry. It might be helpfulto ask questions like, “What usually leads to yourfeeling angry?” or “How does your body tell youthat you are becoming angry?” Examining theseprecipitating factors usually diminishes the inten-sity if the anger and gives the child a sense of con-trol by learning what triggers an angry response.

It is helpful to ask the child what he or shethinks are more appropriate ways to respond to

angry feelings. It is also appropriate for an adultto set a limit with an angry bereaved child who isacting out. “It’s not okay to hit me but you canhit this pillow.” Maintaining household rules andchores actually increases the sense of normalcyand security for a grieving child.

Stephen had been very close to his grandfather

and when he died, his parents noticed he began

bullying his younger siblings and picking fights at

school. They called his football coach who sug-

gested that Stephen might “work out” some of his

aggression by staying after practice and “ramming”

the dummy players. After two weeks of “extra” prac-

tices, Stephen was much less aggressive with other

children.

GUILT AND REGRETSSome children have regrets about negative as-pects of the relationship with the deceased or re-grets about things that did not happen or werenot said prior to the death. Examples might be:“I never told my mother I loved her,” “I lied tomy father and never told him the truth,” “I wasmad at my Mom the day she died,” or “I didn’thave a chance to say goodbye.”

Helen Fitzgerald describes some techniquesthat are useful with children in helping them workthrough feelings of guilt and regret. One sugges-tion is to write a letter to or draw a picture for thedeceased describing their “unfinished business.”Another suggestion is to have the child write anote about what she or he feels guilty about, tiethe note to a helium balloon, and then releasethe balloon into the sky. For younger children,she suggests making two puppets and drawingone puppet face as the child and the other as thedeceased person. The child puppet could tell thepuppet of the deceased what they feel guilty aboutor what they regret about the relationship.

After her mother’s death, Emily’s father noticed

that she seemed very preoccupied and unable to

focus on her schoolwork. After several months,

he referred her to the school counselor who had

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experience in working with bereaved children.

When she suggested Emily write letters to her

mother, Emily seemed relieved to be able to “com-

municate” with her mother in this way. Emily then

asked the counselor to read the letters. They were

full of ways that Emily believed she could have pre-

vented her mother’s death. After several of these

letters and the counselor’s educating Emily on the

nature of her mother’s serious illness, Emily began

to relax and was able to focus on her school work

again.

FEARSIt is important to help fearful children identifywhat they are afraid of specifically and then toaddress each fear individually. Children who arefearful generally need repetitive reassurance thatthey will be OK. It is also important that a parentor other significant adult spend time alone withand focused on the grieving child, reassuring thechild that they are special and loved.

Both of Anwar’s siblings had been killed in an auto-

mobile accident. Anwar was terrified of riding in a

car for months after their death and was also afraid

that someone else close to him would die. His par-

ents and family provided a great deal of love and

support during this time. His father decided to help

him confront his fear of riding in the car by taking

incremental steps. First they sat in the car for a long

time as Anwar expressed sorrow about his loss and

his anger at the driver that hit the car. Later, his

father backed out of the driveway reassuring Anwar

that he was safe. The next day he drove down the

street assuring Anwar about how accomplished a

driver he was. Soon Anwar was able to ride in a car

again without fear.

PHYSICAL COMPLAINTSWhen grieving children routinely have physicalcomplaints like headaches and stomach aches, itis sometimes helpful to ask what other feelingsthey may be having as well. They may not dis-close their emotions right away, but they may be-gin to make their own connection between theirphysical and emotional concerns.

If the physical complaints mirror those of thedeceased, it is helpful to remind a child why thedeath happened. A visit to the pediatrician mayalso be advised, so the child can hear reassurancefrom the doctor that nothing is wrong with them.

Jose complained of headaches for weeks after his fa-

ther’s death. He was the oldest son and felt he had to

be “strong” for his other siblings and for his mother,

so he expressed very little emotion. Two months

after his father’s death, his uncle asked Jose if he

wanted to visit the cemetery. When they arrived,

Jose began to cry when they came to the grave. He

and his uncle spent several hours while Jose talked

to his father and reminisced with his uncle. After

that, Jose no longer complained about headaches.

BEREAVEMENT SUPPORT GROUPS FORGRIEVING CHILDRENChild bereavement support groups are amongthe most successful ways to provide support toa grieving child, particularly for older children.Donna L. Schuurman, Executive Director of theDoughy Center, an agency that specializes in thegrief and loss issues of children, suggests that chil-dren should be grouped by age and developmen-tal level in grief groups. She also suggests thatmixing death types and relationships to the de-ceased are acceptable but that children experienc-ing different losses (i.e., divorce, death) shouldnot be mixed in the same group. Children supportgroups are typically less structured than adultgroups and usually incorporate play time.

One of the most important reasons that be-reavement groups are helpful is that grieving chil-dren discover in the group that there are otherchildren whose experiences are similar to theirs.Being in a peer group with other bereaved chil-dren helps normalize their experience and reac-tions, helps then to understand that their feelingsare important, and allows them to feel hopeful bylistening to other children who are coping suc-cessfully. In bereavement support groups, chil-dren learn that they can express themselves inhealthy ways and also learn tips from one another

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about how to deal with similar emotions and cir-cumstances.

SUPPORT FROM SCHOOLS FORGRIEVING CHILDRENChildren spend a great deal of time in schooland both teachers and peers can be an impor-tant source of support for a grieving child. Teach-ers and school counselors should be told aboutthe progress of the illness while the child’s lovedone is still alive and of the death when it hap-pens. The teacher should be aware of what thechild knows about the illness and could be givenadvice on how best to support the child. Teach-ers can also help by monitoring the child’s emo-tional state and behaviors in the time followingthe death. The school may need to alter assign-ments or provide extra instructional assistance fora grieving child.

The teacher should share with the child’s class-mates’ information about the death and also pro-vide guidance on what they can do and say andhow they might be helpful when the grievingchild returns to the classroom. Children could beprompted to say, “I was sorry to hear about yoursister,” or “I felt sad when I heard about your fa-ther dying.” Welcome back posters or sympathycards are very appropriate.

It is important to remember that some childrenspend more time processing their loss with peersthan with other adults. On the other hand, somechildren, especially older children, do not want tofeel different than their peers and may be hesitantto share their loss as it might single them out asdifferent from others.

PLAY THERAPY FOR GRIEVING CHILDRENA child’s play is often the main avenue throughwhich a grieving child expresses his or her grief,particularly younger children. When young chil-dren are trying to comprehend death, one canoften observe rituals where they bury animalsand insects in the ground or use dolls and action

figures to play out the both the dying and griefprocesses. Through play, children can take aparttraumatic experiences and replay them in a waythat is comforting to them, and they can do thisin relative safety, one step removed from reality.If parents or teachers find that a child’s play hastaken on a rigid, sad, or repetitive character, theyshould talk openly with the child about what isbeing experienced.

Many grief therapists who work with younggrieving children use play therapy to assist thechild in coming to terms with their loss. Theadvantages of play therapy are that young chil-dren tend to have a limited verbal ability for de-scribing their feelings, they tend to have a limitedemotional capacity to tolerate stress and the painof loss, they have a shorter attention span, andfinally, young children communicate their feel-ings, wishes, fears and attempted resolutions totheir problems through play. The goals of ther-apy for the bereaved child are to help facilitate themourning process and to help clarify any cogni-tive confusion the child may have about the death.

GUIDELINES FOR HELPINGGRIEVING TEENS

Table 27–6 presents the “Bill of Rights for Griev-ing Teens.” Written by a grieving teenager, thisdocument, is, in essence, guidelines for how toassist teens who are bereaved.

The most important thing an adult caregivercan do for grieving teens is to be available to them.Availability means being approachable, non-judgmental, caring, and appropriate. Lettingthem know you are there to talk at any time andletting them know you will hear what they aresaying, no matter what it is, will make all the dif-ference in your ability to be a helpful presence forteenagers who have suffered a loss.

Do not assume they will come to you to talk.You will need to ask if they want to talk. And, ifa grieving teen asks, “What do you want to talk

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TABLE 27–6. Bill of Rights for Grieving Teens

A grieving teen has the right . . . .� To know the truth about the death, the deceased, and the circumstances� To have questions answered honestly� To be heard with dignity and respect� To be silent and not tell you her or his grief emotions and thoughts� To not agree with your perceptions and conclusions� To see the person who died and the place of death� To grieve any way he or she wants without hurting self or others� To feel all the feelings and to think all the thoughts of his or her own unique grief� To not have to follow the “Stages of Grief” as outlined in a high school health book� To grieve in one’s own unique, individual way without censorship� To be angry at death, at the person who died, at God, at self, and at others� To have his or her own theologic and philosophic beliefs about life and death� To be involved in the decisions about rituals related to the death� To not be taken advantage of in this vulnerable mourning condition� To have irrational guilt about how he or she could have intervened to stop the death

Written by teenagers at the Dougy Center (http://www.dougy.org/grief-resources/bill-of-rights/); Reprinted withpermission of the Doughy Center, Portland, OR.

about?” tell him or her. Be open and address yourown feelings or difficulties regarding your lovedone’s death. Be honest. Avoid euphemisms suchas, “passed on” or “left us.” Use the deceasedperson’s name or family role (like mother, grand-mother, etc.). It’s also OK to say, “I don’t know”if she or he asks you a difficult question. Don’tpretend to understand something that you don’t;your teenager likely will learn that you don’t, if heor she doesn’t pick up on it immediately. Then beopen to just listening. Ask leading questions thatinvite your teenager to talk to you. Review theconversation, asking your teenager to summarizewhat you discussed. This provides opportunitiesto clarify if there are misconceptions or misun-derstandings.

If you are unable to talk about death with yourteenager, find someone else who feels comfort-able talking about it, like another relative, anotherbereaved teen, or a professional, such as a socialworker, faith practitioner, or school counselor.

Share your own thoughts, concerns, and feel-ings. Acceptable expressions of grief will be

demonstrated by your example. Give yourteenagers permission to grieve by allowing themto see you grieve. Telling stories, reading, andwriting poetry and journaling are all useful meansof expressing one’s grief. These things could beshared with others or not.

Share and discuss religious beliefs with yourteenager. If your teenager has spiritual questionsyou can’t answer, admit it and seek the assis-tance of your faith professional (minister, priest,rabbi, imam). Try not to react negatively if yourteenager is expressing faith or beliefs that are dif-ferent from the accepted family practice. Olderteens especially will be developing their own faithpractices to prepare for future losses. This mayrequire some religious “experimentation” on theolder teen’s part. Refer him or her to your localfaith professional.

Being an adult companion to a bereaved teen,especially if you are a parental figure, may makeyou the focal point of anger and, perhaps, cruelremarks. This can be especially difficult to toler-ate if you are experiencing your own grief. Try

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not to engage the teenager in a way that willresult in building barriers, but shift the focusto the underlying pain the teenager is trying tomask with these remarks. The bereaved teen maynot be approachable at the moment that the re-marks are made; you may want to establish atime to talk in the future and describe what youwant to talk about when making your “appoint-ment.”

Times before, during and immediately after adeath are disruptive. Try to re-establish a routine,with appropriate expectations and limits, as soonas possible. Teenagers as well as younger chil-dren need the reassurance and sense of securitythat comes from structure, rules and limits. Themain difference in an older teen is that you shouldbe open to negotiate the rules and limits appro-priate to the teen’s age. Remembering your ownfears and anxieties during this period of your lifemay help you be less rigid and more reasonablein negotiating rules and limits.

Teens need to be allowed to mourn intermit-tently. Two teenagers who were present for thehome death of their father were seen playingvideo games within an hour of his death. Somefamily members wondered if this was “appro-priate” behavior. It was fortunate that a hospiceprofessional was present to reassure the familythat this was normal, and that teenagers needto be given room to mourn in their own ways.Sometimes the overwhelming nature of the lossrequires teenagers to “take a break” from theirmourning and engage in whatever may distractthem from the loss. Also be ready for mood swingsand emotional expressions at unexpected times.Be prepared for resurfacing of emotions on spe-cial days or anniversaries, such as birthdays, hol-idays, and the anniversary of the death.

The secure presence of some understanding,caring and appropriately affectionate adult rolemodels can make all the difference to a teenager’sexperience of and ability to cope with his orher grief. Remember that each teenager’s griefis unique. Let him or her teach you what the lossmeans and then help the teenager to his or herown meaning as he or she grows up with this loss.

In most cases, teenagers who have experiencedthe death of a loved one will not need professionalhelp. Continuing to live a routine life in a lovingcaring environment of friends, family and com-munity will provide the support and refuge theyneed to learn to live with their loss and preparefor future losses life undoubtedly will put in theirway.

However, in some situations, professional helpis needed. After any experience of violent death,whether that violence is manmade (such as mur-der, an act of war or mob violence) or natural(such as flood, tornado, earthquake, or hurri-cane), the evaluation of a caring family-orientedhealthcare professional may be appropriate. Inthese situations, the possibility of long-term com-plications, such as posttraumatic stress disorders,should be addressed.

Always seek professional help and evaluationif the teen has developed symptoms that are of aconcern to you. Grief is often expressed throughbehavior. Your teenager needs to hear that youcare about him or her even if the teen is actingout. If grief is severe or prolonged, don’t hesi-tate to seek grief counseling for your teenager.Family and friends can provide a wealth of sup-port, when relationships are established that aretrusting and appropriate. Individual counselingcan help address personal issues. Child and fam-ily counselors are a primary source of assistanceto the whole family in grief. Support groups canhelp your teenager feel less isolated and differ-ent from other teens. Peer groups are usuallymore authoritative than parents during the teenyears. A well-facilitated youth group can help im-mensely with teenagers’ grief.

When seeking grief counseling for a be-reaved teen, the first place to go to obtainappropriate help should be the teenager’s pri-mary healthcare provider. The family healthcareprovider can make appropriate referrals to mentalhealth providers or recommend other interven-tions that may be necessary. The provider mayalso help access any insurance benefits that maybe available, or make referrals to public healthresources.

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The teenager’s school may be another impor-tant resource, as a large part of a teenager’s timeis spent at school. If a teenager is having a difficulttime with his or her grief, the school staff, suchas teachers and the guidance counselor should beinvolved. They can be invaluable allies in help-ing a teenager with his or her grief. In addition,guidance counselors often know about commu-nity resources. Inform the teenager’s school guid-ance counselor and teachers of the death, andhow close your teenager was to the deceased. Askteachers and guidance counselors to provide youwith feedback if they see any changes—good orbad—in your teenager’s behavior or performanceat school. Watch for academic decline. Griev-ing teenagers may not be well-rested due to in-somnia or interrupted sleep patterns. They mayhave trouble concentrating in class or completinghomework. Offer assistance and, if necessary, seeif the school can recommend a tutor.

There are also many resources in the gen-eral community. A growing number of commu-nities have bereavement centers with programsfor children and teenagers. Also, many commu-nities have self-help phone numbers or help hot-lines that may list bereavement services availablein your community for children and teenagers.Some communities will have a public mentalhealth center, and these centers often will helpto evaluate and refer teenagers who are hav-ing a difficult time with bereavement, especiallywhen they are depressed, despondent, or un-usually angry. Another source of communityhelp for bereavement care is your local hospiceprovider—even when the deceased was not ahospice patient. Hospices generally provide re-sources and referrals for bereavement care at nocost.

Youth groups that are either recreational, suchas the YMCA or Scouts, or religious youthgroups, may be a useful resource to assist thegrieving teen, as participating teenagers receivenurture and distraction from their routine in awholesome environment. Some of these youthgroups may even provide direct access to coun-

selors who can address and assist with grief recov-ery. One’s local temple, church, or mosque, andthe local minister, rabbi, pastor, imam, or otherspiritual counselor is another important resourceto consider if you are looking for help with be-reavement. Many local faith groups provide be-reavement groups and pastoral counseling thataddress issues of bereavement from a spiritualpoint of view.

The internet can provide a wealth of infor-mation and support for grieving teenagers. Keepin mind that while there is also a lot of inap-propriate information on the internet, there arereputable sites that provide an opportunity toread information and write or start your ownblog (a web site with short entries and links topersonal or other websites on a particular sub-ject, i.e., bulletin boards). Libraries and bookstores offer reading in the area of grief and griefrecovery.

GRIEVING PARENTS NEED TOTAKE CARE OF THEMSELVES

Although this chapter focuses on the care of be-reaved children, one would be remiss in not atleast touching on the need for grieving parentsto care for themselves while caring for bereavedchildren. Many parents find this particularly chal-lenging, which is why it is imperative that adultsmake a special effort to get the support and as-sistance they need so that in turn they can at-tend to the grief needs of their children. Someadults, however, do find it particularly therapeu-tic to give to a grieving child, because it can behealing to provide assistance to someone else. Toensure the best possible interactions can occurbetween grieving parents and children, severalsuggestions are provided in Table 27–7. A fulldiscussion of bereavement care for adults can befound in Chapter 17.

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TABLE 27–7. Suggestions for Grieving Parents� Take time for themselves to sort out their own concerns, doubts, and fears. It is hardfor an adult to be reassuring to a child when they have their own unresolved fears.� Take care of their physical health—rest, eat right, exercise moderately, and avoidalcohol and drugs.� Keep a grief journal, read books about grief, and join a bereavement support group.Many grief experts also suggest waiting on making any major life decisions.� Take people up on their offer to help and support. Relatives and friends can runerrands, take care of the children, or assist with the final arrangements. It is veryimportant not to become isolated.� Allow the child to care about them as well as long as the child doesn’t becomeconsumed with care.� Have someone they can share the responsibility of providing emotional grief supportto the child.

GUIDELINES FOR CHILDRENATTENDING FUNERALS AND

MEMORIAL SERVICES

Therese Rando, a well-known grief and loss ex-pert, explains that rituals allow structure for im-portant events that happen throughout our lives,including death. A funeral offers a controlled timewhere individuals can emotionally and physicallyventilate their feelings. Funeral rituals generatesocial support and offer opportunities to findmeaning, by applying spiritual and philosophicalunderstandings to loss. Funeral rituals are mosteffective when they are personal and involve par-ticipation from friends and family.

When the death of a loved one occurs, adultsare faced with difficult choices about whetherto include children and teenagers in death rit-uals such as funerals and memorial services. Asa general guideline, children should be allowedto attend a wake, funeral, and burial if they wantto. Children can also be involved in the funeralplanning. Joining family members for these ritu-

als gives them a chance to receive grief supportfrom others and a chance to say goodbye in theirown way to the deceased.

Children should never be forced to attend afuneral or memorial service. It is important, how-ever, to understand the children’s reasons for notwanting to attend, so any fears or questions canbe addressed. Questions that might assist adultsin understanding a child’s fears or concerns mightinclude: “What is the thing you are most afraidof about the funeral?” or “What do you thinkyou might feel if you were to go to the memorialservice?”

Always prepare children for what will happenat any death ritual. Describing the funeral pro-cess step by step (what they will see, how otherpeople might react, how they might feel) canhelp allay children’s anxieties about the event.It is important to reiterate that crying or notcrying are both OK. Extra attention and affec-tion from adults may be necessary so childrendo not feel forgotten or neglected, remember-ing not to embarrass a teenager in front of hisor her peer group. It is helpful to make arrange-ments with a trusted adult so a child could leavethe funeral or memorial service early if he or shewishes.

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Children should never be forced to view ortouch the body; they need to be given a choicethat will be respected. If they are going to viewthe body, it is helpful to remind them that deathis final and to describe how the body might look.An explanation could go like this: “Sally will belying in a wooden box called a casket. She willlook like she is sleeping, but she is not. She isdead. Her chest will not rise and fall because sheis not breathing.” For some children, touchingthe body may satisfy their curiosity, be a way ofsaying goodbye, or be an expression of love. If achild decides to touch the body, he or she shouldbe told that the body will feel cold and hard. Somechildren, however, do not need to touch or see thebody to know that the death is real. If a child doesnot want to see or touch the body, an adult couldrelay that the body was seen and that the deceasedwas not living or breathing.

Children should be asked if there is anythingthey would like buried with their loved one. Itis often comforting for the child to place a smallgift, a drawing, a letter, or a picture of themselvesin the casket.

EXPLAINING BURIAL AND CREMATIONTO A CHILDIf the deceased will be buried, it is helpful to ex-plain to children in detail what that means so theywill not develop fantasies about where their lovedone was put to rest. An explanation may go likethis: “The casket will be sealed shut and thentaken to a cemetery where there are several otherbodies buried under the ground (or placed in ahole in the wall of a building called a mausoleum).They have to be placed there because, like with adead squirrel, their body will begin to decomposebecause it is no longer living.”

It is sometimes difficult for a child to under-stand cremation. When describing it, it is impor-tant to remind the child that the dead person nolonger feels anything, so it is not painful. If thechild wants to view the body before a cremation,most mortuaries can arrange for this. When de-

scribing cremation to a child, it might be help-ful to say: “Cremation happens at a place calleda crematory. There they use heat to change thebody into ashes. These ashes are usually placedin a special box and the family decides what theywant to do with the ashes.”

WAYS TO COMMEMORATE THE LOSS WITH AGRIEVING CHILDDuring the grieving process, there comes a timeto bring emotions into perspective, modify pat-terns of thinking, develop a new awareness ofthe loss and the importance of life, and start tofree oneself from the profound pain of grief. Thischange, and it can be a significant one, is facili-tated by the act of commemoration. Commem-orating a loss can be a public or private event,elaborate or simple. The important thing with agrieving child is that the ritual should be plannedwith the child’s consent and is not imposed. Thechild could be asked to actively participate bysharing ideas for commemorating the deceased.

A helpful way to commemorate a loss is tovisit the cemetery or final resting place of the de-ceased. It may be a means for the child to saygoodbye or to satisfy natural curiosity. As withfunerals, it is important to describe to childrenbeforehand what they will see and how they mayfeel at the cemetery, and allow them to ask ques-tions. Often families take flowers, pictures, smallgifts, or notes to place on the grave. It is help-ful if adults share their feelings while visiting thegrave to give permission to the children to shareas well. It is also helpful to process afterwards anythoughts and feelings about the visit.

Phyllis Silverman, William Worden, and oth-ers have described how bereaved youngsters of-ten maintain a connection of some type to thedeceased person who they loved, such as a par-ent. They may believe the parent is somehow withthem when they are awake. There are many rit-uals and activities that children enjoy doing thatenhance a positive connection to the deceased.Adults should allow grieving children ample

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opportunity to share their memories of their lovedone and adults should talk about the deceasedperson as often as possible. Viewing photo al-bums, telling stories, visiting special places wherethey went with their deceased loved one, havingmemorable possessions of their loved one are allimportant commemorative activities.

There are many creative ways to commemo-rate the loss as well. One is to write letters to thedeceased. The letters could be kept in a specialplace, could be shared, or could be burned ina ceremony. The burning of letters is especiallysignificant if there was unfinished business in therelationship, particularly with older children. Art-work can be very therapeutic for grieving childrenas it allows them a nonverbal channel to expressthemselves. It is important to allow children thechoice about whether or not to share their artworkwith others. Some children may choose to writeabout their emotions and memories in a poem,story, or journal. Other creative ideas includemaking a scrapbook or photo album, makinga treasure box where mementos of the deceasedcan be stored, planting memorial trees or plants,and donating money to charity in their loved one’sname.

HOLIDAYS AND SPECIAL ANNIVERSARIESHolidays and special anniversaries can be verydifficult for grieving children and adolescents, es-pecially during the first year. Holidays and an-niversaries serve both as a reminder of the lossand of pleasant memories of the deceased. It issometimes difficult for children to watch othersenjoy the holiday, when for them it just brings upthe void they feel. Often, the anticipation of theholiday can be worse than the holiday itself.

It is important to let bereaved children know inadvance that they might experience some painfulfeelings during the holiday or anniversary. It isalso helpful to plan with them in advance ways tomake these events more tolerable. Holiday ritualsthat included their loved ones could be alteredand new rituals developed.

Mother’s and Father’s Day can be particularlydifficult for children that have lost a parent. Theymay choose to commemorate their loss by visitingthe cemetery or visiting a special place where theyhave positive memories of their parent. If theyare supposed to participate in an activity with theparent, for example, a Mother’s Day celebration,they may choose to take a “substitute mother” tothe event.

As the first anniversary of the death ap-proaches, children often find themselves relivingvery intensely the last days of their loved one’s life.Children often need extra reassurance and sup-port during this anniversary. It is also importantthat the adults in their life share their own feel-ings about the anniversary and memories aboutthe deceased.

Children often choose to celebrate the birth-day of their deceased loved one. They might makea birthday gift for their deceased loved one, orbake a cake and light birthday candles. The cel-ebration could include sharing memories aboutpast birthdays with their loved one. A visit to thecemetery might be a special way to allow a childto say “happy birthday” to their deceased lovedone. Other holidays may be commemorated in asimilar fashion, by giving gifts, sharing memoriesof the deceased, and developing special rituals.

DEATH OF A PARENT OR SIGNIFICANT ADULTParents naturally love their children and childrendepend upon parents for survival and stability.Silverman believes that what a child experiencesas lost along with the death, how they talk abouttheir deceased parent or significant adult, andhow they understand his or her place in theirlives, can be even more critical than age-specificunderstanding of death. The death of a parentor significant adult seems to be more difficult ifthe death was sudden or if the child lacks a solidreplacement figure.

Some children fantasize that their parent willreturn, and others have the wish to die so they canbe reunited with their deceased parent. Usually,

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this is a fleeting desire rather than true suicidalideation. Children expressing these wishes, how-ever, should be questioned more deeply, and aninvestigation made as to whether they do havea specific plan and means available to carry outtheir wishes.

Silverman describes the accommodation andadaptation to the loss of a parent or significantadult that a bereaved child experiences through-out his or her life. These children tend to revisitthe meaning of their parent’s death over and overagain at different developmental stages. They alsore-experience the loss at events such as gradua-tion, marriage, and the birth of a child.

Some bereaved children idealize their parentor significant adult as a way to keep their pleas-ant, comforting memories of them alive. This canbe adaptive unless it gets in the way of a childexpressing angry feelings toward the parent for“leaving” or for any “unfinished business” in therelationship. It is important that surviving parentsallow the idealization of the deceased parent, butalso stress with children how much they love themand reassure them of their care and support.

DEATH OF A SIBLING

When a sibling dies, the surviving child reacts toboth the loss of the sibling and to the change inbehavior and grief process of his or her parents.The grief response of siblings may be longer orshorter than parents and they may have a differ-ent understanding of the death. Siblings are oftenasked numerous questions about their brother’sor sister’s death from their peers and from otheradults. This can feel overwhelming to a child.

An ill child often receives more attention fromparents than their siblings who are well. The sur-viving children often believe they will get more at-tention from their parents after the death of theirsibling and then are disappointed when those ex-pectations are not met. Surviving children mayalso grapple with identity and role issues after the

loss. “Am I still a little brother?” or “Who’s goingto take out the garbage now?”

Sometimes, grieving parents are overprotec-tive of the remaining siblings, concerned that theymay die or become ill as well. Other parents placeunreasonable expectations or demands on the re-maining siblings, for example, asking them to takeon the responsibilities and roles of or to have thesame attributes as the deceased sibling. It is im-portant that parents avoid being either overpro-tective or overpermissive with grieving siblings,despite the temptation. Care should be takento not make comparisons between the deceasedchild and any siblings, as it may lead the surviv-ing children to feel inadequate. Care should alsobe taken not to assign inappropriate responsibil-ities to a child that the deceased sibling used tohave, especially responsibilities that are not de-velopmentally appropriate.

For all these reasons, grieving siblings need alot of reassurance from their parents that they areloved for who they are and that they will be caredfor and supported. They need to be remindedthat they did not cause their brother’s or sister’sdeath. They also should be encouraged to sharememories and hold keepsakes of their deceasedsibling and to participate in family rituals relatedto the deceased child.

CONCLUSION

Bereaved children and adolescents are unique inthat they experience the pain of loss earlier thanother people, earlier than they are expected to.Bereaved children are also unique in that theymay not completely comprehend the meaning of“gone for good,” instead, may hold onto an innerrepresentation of the deceased. Children who aregrieving the loss of a parent or significant adultdiffer from other children in that they lose the in-nocent belief that their parents will be there tocare for them forever. Surviving siblings or chil-dren whose young friends have died are forced

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to face the fact that young people sometimes dieearlier than they are supposed to.

This chapter outlines the typical emotional,physical and behavioral manifestations of chil-dren and adolescent grief and offers guidelinesfor interventions that adults can provide to griev-ing children. When adults really listen to griev-ing children and take their cues for action fromthem, adults learn that what grieving childrenmost need is unconditional love, reassurance thatthey will be cared for, inclusion in the mourningprocess, and availability to work through theirgrief. Adults also can be comfortable that thecommunity at large can play a significant role inthe positive outcome of a grieving child.

When adults talk openly and honestly withchildren about death, especially before the childever faces a loss and if children are given thestraight facts about death, they begin to under-stand death as a natural part of life, instead ofsomething to be feared or something that hap-pens to others and never to them or their fami-lies. This affords children the time necessary tobe able to face the reality of death and to properlymourn, and as a result, attain a positive outcometo their grief process.

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burg Fortress, 1994.

Parker MB: Jasper’s Day. Tonawanda, NY, Kids Can

Press, 2002.

Romain T: What on Earth Do You Do When SomeoneDies?. Minneapolis, Free Spirit Publishing, 1999.

Schwiebert P, DeKlyen C: Tear Soup. Portland, OR,

Grief Watch, 1999.

Shavatt D, Shavatt E: My Grieving Journey Book.Mahwah, NJ, Paulist Press, 2001.

Simon N: The Saddest Time. Park Ridge, IL, Albert

Whitman, 1986.

Van-Si L, Powers L: Helping Children Heal From Loss.Portland, OR, Portland State University, 1994.

Viorst J: The Tenth Good Thing About Barney. New York,

Atheneum, 1972.

Wilhelm H. I’ll Always Love You. New York, Dragonfly

Books, 1988.

Winsch JL: After the Funeral. Mahwah, NJ, Paulist

Press, 1995.

Wolfelt A: Healing Your Grieving Heart: 100 PracticalIdeas for Kids. Ft. Collins, CO, Companion Press,

2000.

Yolen Jane: Granddad Bill’s Song. New York, Penguin

Young Readers, 1998.

Zalben Jane: Pearl’s Marigolds for Grandpa. New York,

Simon & Schuster, 1997.

Books for Teens:Blume J: Tiger Eyes. New York, Random House, 1982.

Fitzgerald H: The Grieving Teen: A Guide for Teenagersand Their Friends. Wichita, KS, Fireside (also avail-

able in downloadable digital edition), 2000.

Fry VL: Part of Me Died, Too: Stories of Creative Survivalamong Bereaved Children and Teenagers. New York,

NY, Dutton Books, 1995.

Gootman M: When a Friend Dies: A Book for TeensAbout Grieving and Healing. Minneapolis, Free

Spirit Publishing, 2005.

Gravelle K: Teenagers Face to Face with Bereavement.Englewood Cliffs, NJ, Silver Burdett Press, 1989.

Grollman EA: Straight Talk about Death for Teenagers:How to Cope with Losing Someone You Love. Boston,

MA, Beacon Press, 1993.

Grosshandler-Smith J: Coping when a Parent Dies. New

York, Rosen Publishing Group, Inc, 1995.

Hughes L: You Are Not Alone: Teens Talk About LifeAfter The Loss of a Parent. New York, Scholastic,

Inc., 2005.

Kolf JC: Teenagers Talk about Grief. Grand Rapids, MI,

Baker. Publishing Group, 1990.

Krementz J: How it Feels When a Parent Dies. New York,

Knopf, 1988.

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Myers E, Adams K: When Will I Stop Hurting? Teens,Loss, and Grief. Lanham, MD, Rowman & Little-

field Publishers, Inc., 2004.

Meyers K: Truth about Death and Dying. New York,

Facts on File, Inc., 2005.

Samuel-Traisman E: Fire in My Heart, Ice in My Veins:A Journal for Teenagers Experiencing a Loss. Omaha,

NE, Centering Corporation, 1992.

Wolfeldt A: Healing Your Grieving Heart for Teens: 100Practical Ideas. Fort Collins, CO, Companion Press,

2001.

Internet Resources:http://www.centerforloss.com/.

http://kidsaid.com/.

http://www.newhope-grief.org/teengrief/.

http://www.wnyafn.com/teengrief/.

http://www.dougy.org/.

http://www.centeringcorp.com/catalog/index.php.

http://www.compassionbooks.com/store/.

http://santaclaracountylib.org/kids/lists/death dying

grieving.html.

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SELF-ASSESSMENT QUESTIONS

1. All of the following are myths associated withchildren and grief in this culture EXCEPT?

A. It is best to protect a child from experi-encing grief

B. Children should only be allowed to attendfunerals and memorials if they choose to

C. Children do not have the capacity to reallyunderstand death and grief

D. Children are more resilient than adultsand quickly “bounce back” after a loss

2. All of the following are considered typicalgrief reactions for infants and toddlers (untilabout age 4) EXCEPT:

A. Anxiety related to the separation from amajor attachment figure

B. Understanding that death is final and ir-reversible.

C. Irritability, protest, and cryingD. Changes in eating and sleeping patternsE. Do not envision that death is something

that can happen to them

3. All of the following are considered the impor-tant factors that influence how a child andteenager respond to grief and loss EXCEPT:

A. Developmental level and chronologic ageB. Nature of the relationship with the person

that has diedC. Child’s own personalityD. What they are taught about death and

grief from adultsE. Whether they know how to read or not

4. Which of the following behaviors exhibitedby a child to the loss of a significant loved oneis most likely to require trained, professionalhelp to resolve?

A. Memory difficultiesB. Searching behaviorC. Difficulty concentrating

D. Preoccupation with memories of the de-ceased

E. Idealization of the deceased

5. According to Alan Wolfelt, all of the followingcharacteristics indicate that a child is begin-ning to adjust to the loss of a significant lovedone EXCEPT:

A. Return to stable eating and sleeping pat-terns

B. Decision to forget their loved one andmove on

C. Increased thinking and judgment capabil-ities

D. Establishment of new and healthy rela-tionships.

6. Which of the following is considered a com-plicated grief reaction in a teenager?

A. Assuming mannerisms, traits or wearingclothes of the deceased.

B. Emotional regression and even bed-wett-ing, which can be most upsetting for teen-agers.

C. Becoming overly responsible (the “new”man or woman of the house)

D. Prolonged sleep disturbances, includinginsomnia and nightmares

E. Needing to repeat again and again storiesof their loved one

7. All of the following are considered behaviorsassociated with complicated grief in a childor teenager EXCEPT:

A. Excessive rumination about havingcaused the death

B. Extreme withdrawal, isolation, and inabil-ity to socialize with others

C. Pervasive fantasies that get in the way ofnormal functioning

D. Anger and lashing out seemingly for noreason

E. Persistent assumption of the mannerismsof the deceased, including those not de-velopmentally appropriate

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8. All of the following are considered appropri-ate interventions in preparing a child for thedeath of a loved one EXCEPT:

A. It is important to wait to tell the child untiljust before the loved one dies so the childdoes not carry unnecessary anxiety priorto the death.

B. The child should be told that the imagesthey see of death in television cartoons arenot always authentic and that death is ir-reversible

C. The adult should use adjectives like “veryvery old” or “very very sick” to help thechild distinguish between getting a coldand someone with a terminal illness

D. If the child is old enough to understandwhat is happening and both the child andthe dying person would like the visit, thechild should be allowed to visit.

E. If the child does not want to visit, a sup-portive adult should attempt to elicit whythe child is resistant, but the child’s wishesshould be honored.

9. All of the following are helpful interventionsby an adult who is trying to help a grievingchild EXCEPT:

A. Assure the child with specifics about howhis or her care giving needs will be met.

B. Keep the child in their environment andcontinue their routine as much as possible

C. Tell the child that God wanted their lovedone and that is why he or she died can becomforting to a child.

D. Adults should not use children as theirsole support during their grief.

E. Respect a child’s desire to not talk abouttheir grief

10. All of the following are helpful interventionsthat an adult can use with a grieving childwho is angry EXCEPT:

A. Be direct and ask the child to “calmdown.”

B. Help the child dissipate the anger by run-ning or exercising

C. Involve the child in art work such as scrib-bling, ripping paper, sculpting dough, etc.

D. Ask questions like, “What usually leads toyour feeling angry?” “How does your bodytell you that you are becoming angry?”

E. Ask the child what he or she thinks aremore appropriate ways of responding toangry feelings.

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