Treating Grief and Loss in Children and Teens
by Meghan Harris, Psy.D.
In “The Nature of the Child”, Jerome Kagan wrote, “the effects of most experiences are not fixed but depend upon the child’s interpretation.” Nowhere is this more true than in the seemingly unlikely area of bereavement. Treating children who have experienced the death of a loved one, whether through accident, illness, homicide or suicide, is always unpredictable. It is often the child’s interpretations which make all the difference in their coping and adaptation. And is loss always for the worst? It can rob children and adolescents of many different aspects of life; but can also bring unexpected gifts, depending upon the variables at play in the child’s world.
Grief is conventionally defined as the emotional response to loss, but it also has physical, cognitive, behavioral, social, and philosophical dimensions – even with infants. When treating bereaved children and teens, the clinician must come to understand each of these variables in a given situation, and then explore the impact of each of these with the child’s caregivers, and sometimes with the child themselves.
The following list is adapted from The Dougy Center, The National Center for Grieving Children and Families in Portland, Oregon – an excellent resource for grief and loss work with children and teens.
Age. The first crucial variable to consider is the child’s developmental stage. The age and cognitive abilities of the child and will influence the attachment bonds, and therefore the grief and mourning processes of the survivor. Educating caregivers about what to expect at different stages of the child’s development is essential; it can often help prevent a misinterpretation of a child’s behavior or mood (regression, acting out, lack of crying, inappropriate giggling) as pathological, or oppositional.
Relationship. A second variable is the child’s relationship to the deceased. Was it a sibilng who died? Grandparent? Nurturing parent? Abusive parent? Breadwinner? The complex nature of close family relationships often means a complex picture and experience of grief. A child may feel sad, angry, relieved, guilty, and numb all within a short time.
Support.We know that a child’s support system can help determine their level of resilience after a trauma. Not only are external supports necessary, but the child’s internal supports, their beliefs about themselves also factor in here. These internal and external supports have everything to do with the child’s family, community, school, and spiritual resources.
Specific Nature of the Death. Whether the death was anticipated or unanticipated will influence the way the child or adolescent feels about it, especially in the immediate aftermath. The cause of death, too, is important. Was it accidental? The result of a chronic illness? A suicide? Imagi for a moment, the way in which adults communicate with children about a suicide. This will impact the child’s grieving process, not to mention the other impacts of how their peers react and behave.
As if these factors weren’t enough to consider: each child brings to an experience their own unique history, personality, coping style, and temperament. Grief for a motor-driven child who has ADHD does tend to look quite different from grief of a quiet, introverted teenager.
The bottom line for clinicians and caregivers: every child grieves differently. Helping caregivers respect and even support different grieving styles is essential to the healing process for a child. Grief work is essentially family, and even community work; rarely is it primarily dyadic between the kid and clinician. With so many variables to juggle and weigh – what’s a clinician to do?
Fortunately, Dr. Alan Wolfelt, head of the Center for Loss and Life Transition in Colorado, has spent decades developing a model of “companioning” bereaved children instead of “treating” them. His numerous publications are as practical as they are touching. He has outlined “the 6 needs of mourning” necessary for the child or teen to make meaning out of the loss (2001):
1.) Acknowledge the reality of the death – this includes both allowing the kid to come to terms with the reality at their own pace, and also being honest with the child about the cause and nature of the death. Too often, my role as clinician has begun with helping a family to be honest with a child about how their loved one actually died, in a developmentally appropriate manner.
2.) Feel the pain of the loss – Often, adults try to protect children from pain. However, moving toward the pain of the loss is the only way through it. Some children and teens might be more comfortable expressing their emotions through actions or expressive arts, rather than words.
3.) Remember the person who died. The person’s name is not taboo – memories, especially shared ones, often help heal.
4.) Develop a new self-identity. With the death of an attachment figure, especially within a family, roles change. Relationships shift. Settling into a new normal takes time, especially for a child or teen whose identity isn’t yet fully formed at the time of the death.
5.) Search for meaning. After a death, kids often struggle with the same big philosophical questions as adults: “How could this happen? Why did this happen?” They need support and encouragement while trying to figure out the meaning of life and death.
6.) Receive ongoing support from caring adults. This is perhaps the most obvious way to help, but it’s often the hardest to ensure. Accepting that death also impacts children is sometimes overwhelming for adults, especially if they themselves are grieving. (Not to mention many adults in their own lives have not yet come to terms with their feelings about death and loss.)
Psychologists have a yen for the explanatory narrative. The proof of causation, however, is often quite another story, and debate over links between adult psychopathology and early loss is lively. Many studies point to a clear link between death of an attachment figure and later maladaptive traits. The findings of Felitti, Anda, and Nordenberg et al (1998) conclude that strong evidence exists that “bereaved children are at higher risk of negative sequelae such as mental health problems, including mood disorders, posttraumatic stress disorder (PTSD), and somatic complaints, as well as greater external locus of control, lower self esteem, and more academic difficulties.” Yet despite these sorts of truths we clinicians hold to be self-evident, other truths are emerging. For instance, one study measuring risk behaviors related to unintentional injury, violence, sexual behavior, alcohol and other drug use found that bereaved offspring did not engage in more health risk behaviors compared with their nonbereaved peers (Muniz-Cohen, Melhem, and Brent, 2010).
Descriptive research is one thing; constructive solution-oriented treatment research is another. There is a growing wave of studies which measure not just failures and successes, but interventions. One example which elegantly interweaves clinical intervention with biological and behavioral measures suggests that a family-focused intervention for parentally bereaved youth helped modulate cortisol secretion, thereby decreasing future emotional dysregulation and associated externalizing problems (Lueken, Hagan, & Sandler, et. al, 2010). These types of studies guide us toward constructive interventions, and give us clinical tools to use, rather than simply agreeing with conventional wisdom that children who lose an attachment figure are somehow doomed.
Clinicians stand at the crossroads between healthy development and psychological distress. If Kagan is right, then we have a bully pulpit – or perhaps therapy office – from which we can reach children and teens who have experienced the death of a loved one. Perhaps most importantly, we can reach their families as well, and help all concerned toward the goal of healing. When working with children who have experienced the death of a loved one, clinicians can do what they do best: listen. Then help the adults involved to understand and empathize. Kids grow best when adults can help them process both what a death can take away – feelings of identity and safety – and also what it can give: a broader understanding and appreciation of themselves, the world, and others.
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35 Ways to Help a Grieving Child. (2010). Portland, OR: The Dougy Center The National Center For Grieving Children and Families.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., & Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-58.
Kagan, J. (1984). The nature of the child. New York: Basic Books.
Luecken, L.J., Hagan, M.J., Sandler, I.N., Tein, J.Y., Ayers, T.S., & Wolchik, S.A. (2010). Cortisol levels six-years after participation in the Family Bereavement Program. Psychoneuroendocrinology. 35(5), 785-9.
Muñiz-Cohen, M., Melhem, N.M., Brent, D.A. (2010). Health risk behaviors in parentally bereaved youth. Archives of Pediatric and Adolescent Medicine, 164(7), 621-4.
Wolfelt, Alan D. (2001). Healing a teen’s grieving heart: 100 practical Ideas for families, friends, and caregivers. Fort Collins, CO: Companion Press.
Wolfelt, Alan D. (1996). Healing the bereaved child: grief gardening, growth through grief and other touchstones for caregivers. Fort Collins, CO: Companion Press.
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For more about Meghan Harris, Psy.D., visit: http://drmeghanharris.com/
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Please visit http://www.marincountypsych.org for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.
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The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.