Abstract
A program of education and support is essential for children and their parent or adult caregivers when the children have experienced the death of a significant person. Children need guidance on how to deal with their profound feelings of grief. The purpose of this article is to give school nurses the ability to help children face the strange new world that follows the death experience. The review of literature defines commonly used terms, describes the mourning process experienced by children, and offers school nurses basic information about grief. The article presents the critical elements necessary for planning and implementing a 6-week grief education and support program that offers children and their parent or adult caregivers permission to grieve and the tools with which to process grief.
INTRODUCTION
On the morning of May 13, 1982, 6-year-old Charles and his brothers awoke to noise in the house. Because such a ruckus was unusual that early in the morning, Charles was anxious to see what the fuss was about. When he walked into the living room, Charles saw his mom’s best friend on her way out and smiled brightly to greet the visitor. The friend could only meekly say, “Hi,” and hurry on her way. Next, Charles saw his mom who explained what was happening. The previous night, the Air Force C-130 piloted by his father had crashed, killing all aboard. Charles cried and cried.
Over the next several days, Charles’s house became a place of much activity and confusion. Friends and family came, bringing snacks and gifts. Charles was even excused from school. The visitors told jokes and stories and did whatever they could to entertain Charles and his three brothers. Strangely, the days after his dad’s death were filled with both moments of enthusiastic euphoria and periods of intense sadness for Charles. When Charles was forced to take a nap or go to bed at night, he could no longer block out thoughts about his dad’s death, and he cried until he fell asleep. Eventually, the visitors quit coming. All the snacks they brought were either eaten or stale. But for Charles and his brothers, the dark cloud of intense sadness remained.
The healing and the mourning process were now supposed to begin. But how could they? Dealing with death is a challenge to even the wisest and the most experienced health professional. For a 6-year-old who does not fully comprehend the concept of death, it was an impossible task. No one had helped Charles cope with the complex feelings of sadness and the emotions that continued in the following months when his dad did not return. Everyone wanted Charles to be healed and happy again, but no one realized that for the healing and the mourning process to begin, someone had to give Charles permission to be sad and teach him how to grieve. In that era, teachers, counselors, and school nurses did not know how to assist Charles through the harrowing stages of grief.
REVIEW OF LITERATURE
Definition of Terms
Grief. The total response to the emotional experience of loss through death of a significant person manifested in the psychological, social, and somatic reactions of children.
Bereavement. The state of suffering a loss through death causing subjective responses experienced by children after the death of a significant person.
Mourning. The behavioral process through which grief is eventually resolved or altered and is influenced by cultural response and spiritual beliefs (Rando, 1993). Wolfelt (1998) said mourning is “grief gone public” or “sharing one’s grief with others” (p. 8).
Tasks of Mourning
There is no magic formula for grieving. No one, neither adult nor child, grieves in the same manner. Worden (1996) suggests that children be encouraged to accomplish the four widely recognized tasks of mourning. Grieving children can accomplish the tasks in any order, and they can revisit and rework any task at any time. Worden’s four tasks of mourning are as follows:
Accept the reality of the loss. Before children can deal with the emotional impact of the loss through death, children must believe that the deceased person is dead and will not return to life. Therefore, children must be accurately informed about the death in age-appropriate language.
Experience the pain and emotional aspects of the loss. Children must acknowledge and work through the variety of emotions associated with the death. The feelings children experience include sadness, anger, guilt, anxiety, and depression. If these feelings are not dealt with, they may eventually manifest themselves in other ways such as somatic symptoms or aberrant behavior patterns. The outcome of a child’s mourning process is strongly related to the way parent or adult care-givers cope with the grief and changes in their life. This is especially true if the bereavement is brought about by a traumatic death. When children see an adult express grief without being overwhelmed, that serves as a confidence model for children (Black, 1996). Conversely, if children see an adult dysfunctional with grief, they may be frightened of feelings in general and of their own feelings in particular (Worden, 1996).
Adjust to an environment in which the deceased is missing. For children, adjustment to the environment in which the deceased is missing is determined by the roles and relationships the dead person played in their lives. Children do need to adapt to the loss of roles that have died with the dead person. A mother’s death normally results in many more daily life changes than does a father’s death. In either case, those changes significantly affect the emotional outlook and create major disruptions to which children must adjust (Worden, 1996).
Relocate the dead person within one’s life and find ways to memorialize that person. As Albom (1997) noted, “Death ends a life, not a relationship” (p. 174). The task for children is not to give up the relationship with the person who has died, but to find a new and appropriate place for the dead person in their own emotional life. Worden (1996) said children seek not only to have an understanding of the meaning of death, but also to sense who this now-dead person is in their life. Although the death is permanent and unchanging, the process of understanding is not; it becomes a part of their ongoing life experience. Children must be helped to transform the connection to the dead person and place that relationship in a new perspective rather than be separated from the deceased (Worden, 1996).
GIVING CHILDREN PERMISSION TO GRIEVE
A seemingly simple yet important step in the mourning process is giving oneself permission to grieve. For children, this can be difficult because well-intentioned adults often prevent children from confronting the topic of death. Kubler-Ross (1969), in describing the bereavement of children in our society, spoke of a world in which death is viewed as taboo and discussion of death regarded as morbid. Children are often excluded from discussions of death because parent or adult caregivers believe it is “too much” for them.
Although children do sense that something is wrong when death occurs, they are not allowed to talk about who, what, when, where, and why a death has occurred. Children begin to distrust parent or adult caregivers who exclude them from the real discussions about the death, deny them an accurate version of the story, avoid addressing their questions, or shower them with gifts as a substitute for an opportunity to understand the death they are not permitted to grieve. Children eventually regard the death as a frightening, mysterious, traumatic experience with untrustworthy parent or adult caregivers who offer them no way to cope. In time, children become aware of intense feelings of grief and changed family structure. The effect on children depends on their age and personality and can lead to unresolved grief (Worden, 1996).
Parent or adult caregivers who shield children from the death experience contribute to the problem. They build a protective wall around children and fear the mourning process because it causes the children stress and anxiety. Talking to children about death is upsetting for many adults. They fear their own emotional reactions and the effect these reactions will have on children. Children know that something is wrong, however, even if they cannot fully understand it (Black, 1996; Schaefer, 1988).
Helping children mourn and process grief is important because of the profound consequences. Bereaved children have a significantly increased risk of developing psychiatric disorders. They also suffer considerable psychological and social difficulties throughout childhood and even later in adult life. The long-term risks of bereavement in childhood are associated with inadequate physical and emotional care, especially after the death of a mother. Children who are bereaved by catastrophic events are particularly at risk for psychiatric disorders (Black, 1996). Therefore, children must be given permission to grieve, must be included in discussion concerning the death experience, and must not be shielded from the pain of grief. There is currently an increase in resources for children that focus on the process of dealing with death and dying, but the need to offer grief education and support to children remains a strong priority (Corr, 2002).
Healthy Mourning
Healthy mourning during the bereavement process requires grieving children meet their social and physical needs and achieve healthy adaptation. Davidson (1984) noted five factors that lead to healthy mourning and healthy adaptation: (a) maintaining a nurturing, supportive social network; (b) having an adequate nutritional balance; (c) having an adequate fluid intake; (d) engaging in daily range of motion exercises; and (e) maintaining daily rituals of rest.
Developmental Level
When discussing death and dying with a child, one must consider the child’s developmental level. Each child’s cognitive, emotional, spiritual, and physical response to the death is different and unique. The developmental level affects the mourning process. It is important not to fit a child’s perception of death into a fixed category. The meaning of death is reexamined as life changes and the child matures (Grollman, 1995). To be able to accept the reality of death, a child must comprehend the nature of abstractions such as finality and irreversibility. The child’s relationship to the physical and social world is acquired through reality testing. A child who does not have this ability has difficulty understanding the reality of the death (Worden, 1996).
Children are vulnerable when dealing with the grief related to death because, even though they do have the cognitive development with which to understand the permanency of the death, they may lack the ego and social skills to deal with the intensity of the feelings of death (Worden, 1996). There is a tendency to retreat to an earlier childhood level where there was a sense of protection from death and its consequences; however, social expectations will compel the child to act more adultlike. Some children cry and express deep feelings only in private and do not deal with the grief unless given permission and support (Rando, 1984; Wolfelt, 1996).
For children, death elicits shock, denial, great anxiety, and distress. Their independence is fragile, and the shock of parental loss can reawaken feelings of fear, insecurity, and helplessness. Children often attempt to control these feelings and put on a facade of independence and coping, which heightens their denial, anxiety, and distress. They fantasize and idealize the relationship with the dead. Children have feelings of denial because they fear losing control of emotions and are threatened by the idea of mortality. Children try to act grown-up in an attempt to master the pain of their loss and will deny helplessness. They tend to exhibit fearful, phobic behaviors and hypochondrias (Rando, 1984; Worden, 1996). The nature of the child’s relationship to the deceased and the cause and circumstance of death will also have an impact on how a child grieves (Corr, 2002; Worden, 1996).
Of all the emotions experienced, anger is the most easily expressed and gives the child a sense of power to counteract fear, insecurity, and helplessness. Anger can also fuel depression, however, or be used inappropriately to punish oneself or others for the death. Children expressing anger are often incorrectly labeled as exhibiting unacceptable, irresponsible behavior. Consequently, children lose support for the mourning process and instead receive punishment for behavior deemed as unacceptable.
Altered Family Relationship and Roles
The family unit plays a significant role in the mourning and healing process. The family needs a network of support, understanding, and encouragement. Lack of support and stability can hamper later adjustment and functioning (Rando, 1984; Wolfelt, 1996; Worden, 1996). Death causes a change in family relationships and roles. Normally, the family functions as a unit with each member having defined roles. After a death, there is a missing piece. The family must adjust to the changes in roles and relationships to restore the homeostatic balance of the family (Heiney, Dunaway, & Webster, 1995). The death of a parent also results in collateral losses for children such as changed financial status and geographic relocation that require changes in friends, school, and church. Such added losses can overwhelm children and cause them to retreat from life. Children may also begin to feel they no longer belong to a family, particularly if they have lost a parent through death.
GRIEF SUPPORT FOR CHILDREN
Helping children through the mourning process is good preventive care. Grieving children require stability, security, and the freedom to be curious and express feelings. They also require permission to cry, be angry, talk about feelings of guilt and hurt, and express themselves (Goldman, 2000; Wolfelt, 1998). Primary preventive care involves (a) preparing children for bereavement, (b) supporting parent or adult care-givers during bereavement, (c) explaining and talking openly with children about their experience, (d) encouraging children to be involved in shared mourning practices and the resumption of normal activities, and (e) providing early professional help (Black, 1996). The potential long-term effects of not providing help through the grief and morning process include difficulties with future intimate relationships, reduced vocational success, and difficulties in experiencing general joy of life (Wolfelt, 1996).
Communicating with children experiencing grief due to the death of a significant person is important. Open communication within the family enables family members to have a shared understanding of the death, provides social support within the family system, and allows children to receive support from the surviving parent or adult caregivers. Parent or adult caregivers need to listen attentively by paying attention to the child’s total message, verbal and nonverbal, noting whether these communications are congruent. One cannot assume that children do not think about the death of a significant person (Worden, 1996). Parent or adult caregivers, school nurses, teachers, and counselors must respect the responses of children. Surviving caregivers must patiently, compassionately, and gently encourage children to share their grief feelings and reactions (Wolfelt, 1996).
Therapeutic Interventions
Therapeutic interventions that provide useful support to children in the grieving process include the following:
Normative Information. Normative information is critical to understanding the reaction to death, a primary step in recovery (Black, 1996). When children learn their feelings are normal, they begin to see themselves as normal and are more likely to express their grief, thoughts, and feelings in a healthy, appropriate manner (Goldman, 1997). Part of the normative information process involves providing children with an adequate and honest explanation of the cause of death. Using correct terms such as “die,” “death,” and “dead,” is important. Vague terms or euphemisms such as “passed away,” “gone away,” or “lost,” only cause the child a false sense of hope that the person who has died will return. The child will become frustrated and distrustful when the deceased does not return (Berg, 1991; Grollman, 1995; Heegaard, 1990; Schaefer, 1988).
Personal Story Telling. Encourage children to tell their story of the death and the grief experience. Telling their story helps children discover that their perceptions of facts change. Telling their story aids in achieving an accurate perception of the death event and helps to distinguish reality from imagination. The initial impression of what happened may be incomplete or inaccurate. Most important, when bereaved children can tell their own personal story, they begin to recover their basic life orientation (Davidson, 1984).
Question Answering. Children repeatedly ask questions. They seek information to confirm the permanence of the death story and the reality of the death. When children are not given accurate information, they will create information to complete the story. Unfortunately, such information can be more frightening to children than what really happened (Worden, 1996).
Play. Play is a natural method of self-expression and communication for children. Children are able to explore and express feelings in play they are unable to express verbally. They use play to learn the meaning of the death in their lives (Smith & Boardman, 1995; Wolfelt, 1996).
Art Therapy. Art therapy uses active methods to experience thoughts and feelings (Smith & Boardman, 1995). It allows destructive energy to be expressed in a constructive manner. Art aids children in discovering new ways to respond to grief and death and to create new situations to try out new decisions and feelings. Art therapy objectives include developing self-awareness, expressing energy and feelings, completing problem resolution, and developing spontaneity, creativity, and joy (Davis, 1989).
Reminiscence. Children require help remembering the person who died. Respect and observe dates that preserve the child’s memory of the deceased such as birthdays and anniversaries. In normal grief, children must be reminded of the love, concern, pride, and joy that had characterized the relationship with the deceased (Rando, 1984). Parent or adult caregivers must explore with children the attachment to the deceased person including what was liked and disliked. Not all attachments are positive. Some attachments can be complex or dysfunctional. It is important to listen to children as they reminisce by using active listening and empathetic inquiry focusing on the children’s responses, both positive and not so positive (Corr, 2002).
Bibliotherapy. Bibliotherapy seeks to help the bereaved through the use of books. Carefully select books that are unique to the needs of the children and can help them with a variety of life difficulties related to the death experience. Reading offers an opportunity to identify with others and helps children to realize they are not alone (Miller, 2000; Wolfelt, 1996). Several useful books and workbooks are listed in Table 1.
Memory Books. Memory books give children a tool to record memories that connect with the dead person (Goldman, 2000; Heiney et al., 1995). In the memory book, children can place pictures they draw, stories they write, and photographs they select. Children fear they will forget the deceased person. A memory book gives children a tangible link to the deceased. Pictures of the deceased help children recall associated feelings that remain available for resolution (Goldman, 2000; Rando, 1984).
Music Therapy. Music therapy aids in relaxation and helps children visualize peaceful scenes or images or evokes positive emotions such as love, joy, and deep peace. When music holds the attention of children, it can be an effective intervention because it serves as a distracter from unpleasant stimuli (White, 2001). Music influences the body state by reducing blood pressure, respiratory rate, heart rate, muscle tension, and stress (Dossey, Keegan, & Guzzetta, 2000).
Journal Writing. Journal writing facilitates self-reflection and is a powerful method for children to keep track of changes as well as personal healing. Unstructured journaling provides a record of grief and allows children to connect feelings with thoughts, memories, beliefs, behaviors, and expectations about the future. Journaling enables children to identify patterns of effective and ineffective coping (Dossey et al., 2000).
Letter Writing. Writing a letter to the deceased can be useful if the child understands the finality and irreversibility concepts of death. Letters can express what the child wanted to say to the deceased person such as caring statements or requests for forgiveness for something done or not done, said or not said before the death (Goldman, 2000; Worden, 1996). Letter writing gives tangible expression to thoughts and feelings of which the child may be unaware. The letter can be placed in a journal or disposed of in a number of ways (Dossey et al., 2000). Letters can be disposed of by digging a hole at the cemetery to bury the letter or by burning or ripping up the letter.
GRIEF EDUCATION AND SUPPORT SESSIONS
As a member of the Medcenter One College of Nursing faculty in Bismarck, North Dakota, the author developed this Grief Education and Support Program. The program targets children (aged 6–11 years), young adults (12 years and above), and parent and adult care-givers who have experienced the death of a significant person. Ground rules for the Grief Education and Support Program that apply to all participants are presented in Table 2. The program provides both grief education and individual support, forming an environment that facilitates the grief work necessary to promote healing. Goals for the Grief Education and Support Program are listed in Table 3. Objectives for each Grief Education and Support Session are listed in Table 4.
Group facilitators are volunteers from the community and include teachers, social workers, nurses, counselors, parish workers, and funeral directors. The Program Coordinator presents facilitator training before each Grief Education and Support Session. Books and information are available for facilitators. Web site references for Grief Education and Support Program facilitators are listed in Table 5.
Group facilitators plan and implement each session. One facilitator is assigned to each four participants in the children’s groups and the young adult’s groups. One facilitator is assigned to each of six participants in the adult groups. Group facilitators seek to provide a healthy model of the mourning process. They use discussion, educational videos, and materials designed to help participants understand and work through their grief. The format for each Grief Education and Support Session is found in Table 6.
The Grief Education and Support Program is offered at no cost to children and their parent or adult care-givers twice a year. Each of the six weekly sessions is 90 min long. The Medcenter One Health System provides flyers and letters announcing the Grief Education and Support Program and provides the handouts distributed to participants at each session. Local funeral homes provide monetary donations to help defray program costs. The Grief Education and Support Program is promoted through marketing efforts that include flyers, public service announcements, and letters mailed to churches, funeral homes, school counselors, mental health counselors, and hospice personnel. Personal invitations to grieving families are often made through funeral home and hospice personnel. Word of mouth also has been a valuable marketing tool.
The Grief Education and Support Program serves the community’s children, young adults, and parent or adult caregivers who have experienced the death of a significant person. The participants attending the grief education and support sessions have evaluated the program positively. Children’s comments include the following:
“I’m glad I came.” “It gave me a chance to meet others who are like me.” “I got to draw pictures about my mommy, who died.” “I got to talk about what happened to me to other kids.” “I met nice people.”
Feedback from parent or adult caregivers includes the following:
“I came for myself and also for my children.” “I appreciate the education and support being available for the children.” “The kid’s sessions were great. My son benefited from them.”
Young adults indicated that they enjoyed and appreciated the opportunity to participate in discussions and information sessions with adults.
There is a universal need to establish such programs in other communities. Grief, bereavement, and mourning in children and young adults are often ignored at significant social cost. No amount of knowledge or training can undo the tragic consequences of death. One can, however, educate children to help them understand what has happened and support children to help them develop the ability to cope with their new lives. It is important to remember and acknowledge that children do grieve the death of a significant person. Only by inclusion of grieving children, young adults, and their parent or adult caregivers in honest, open, and supportive discussions of grief, bereavement, and mourning will they be able to deal successfully with its consequences. Furthermore, the quality of the grief education and support they receive will affect the cohesiveness of the family unit and affect the outcome of the grieving child’s life.