General Guidlelines for Caretakers of Children Experiencing Death by Bruce D. Perry, M.D., Ph.D.
DRAFT March 29, 1995 version 2.0
ChildTrauma Academy Programs
Department of Psychiatry and Behavioral Sciences
BAYLOR COLLEGE OF MEDICINE
One Baylor Plaza
Houston, Texas 7030
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Core Principles For Helping Grieving Children
This Guide articulates some issues related to understanding a child's complex set of reactions to loss as a result of a traumatic death. While focused on traumatic death, this information may be helpful to families, case workers, teachers and other adults working and living with any grieving children. This simple guide is intended to inform and provide general principles -- it is not intended be comprehensive or to exclude other observations or approaches to helping grieving children.
1. Do not be afraid to talk about the traumatic event.
Children do not benefit from 'not thinking about it' or 'putting it out of their minds'. If a child senses that his/her caretakers are upset about the event, they will not bring it up. In the long run, this only makes the child's recovery more difficult. Don't bring it up on your own, but when the child brings it up, don't avoid discussion, listen to the child, answer questions, provide comfort and support. We often have no good verbal explanations, but listening and not avoiding or overreacting to the subject and then comforting the child will have a critical and longlasting positive effect.
2. Be honest, open and clear.
Give children the facts regarding the death. While there is no need to describe great lingering detail, the important details should be given. These often are horrifying but it is important to give factual information to the child -- the imagination of a child will 'fill in' the details if they are not given. Too often these imagined details are distorted, inaccurate and more horrifying than the actual details and can interfere with the long term healing process.
3. Be prepared to discuss the same details again and again.
Expect to hear things from the child which indicate that they didn't 'hear' you when you told them the first time. The powerful, pervasive implications of death for the child can be overwhelming -- a traumatic event. The child's responses to death of a parent, sibling or other loved one will be similar to the child's responses to other traumatic events. This will include emotional numbing, avoidance, sadness, regression, episodic manifestations of anger, frustration, fear of the unknown (future), helplessness and confusion (see CIVITAS Booklet: Effects of Traumatic Events on Children).
The child will have recurring, intrusive and emotionally-evocative recollections of the loved one and about the death of the loved one.
If there is no clear image of the death, the child will 'imagine' various scenarios. These images will return and return. As they do, the child (if he or she feels safe and supported by the adults around them) will ask about death, the specifics of the death and the loved one. Patiently, repeat clear, honest facts for the child. If you don't know something -- if you also have wondered about the nature of death or a detail in this specific loss -- tell the child. Help the child explore possible explanations, let the child understand that you and others can and, often, must live with many unknowns. In this process, let the child know, however, that there are things we do know -- things we do understand. Bring positive memories, images and recollections of the loved one into the conversation.
4. Use age-appropriate language and explanations.
The timing and language used in this process is important. In the immediate time period following the death, the child will be much less 'avaiiabie' to receive and process information. As the child gets further away from the event, they will be able to process more, digest more, understand more. During this long process, the child continues to have opportunities for reexperiencing -- for hearing the same material again and again. The child will experience and process the very same material differently at different times following the death. In the long run, the opportunity to reprocess will facilitate the development of a mature understanding of the loss.
Children at different ages have very different concepts of death.
Very young children may little appreciation of the permanent quality of death. Try not to associate sleep and death. When these two become associated, it is not surprising that children become afraid of sleep. They become afraid of loved one's going to sleep. Try to get some understanding from the child of what they think death is -- do they have a view of afterlife, are there specific fears about death and so forth. The more you understand about the child's concept of death, the easier it will be for you to communicate with the child in a meaningful fashion .
5. Help the children avoid false reasoning about the cause of the death.
Young children often make false assumptions about the causes of major events. Unfortunately these assumptions may include some sense that they were at fault for the event -- including the death of a loved one. Adults often assume that causality is clear -- dying in a car accident, being shot in a drive-by shooting, dying in a fire. The child may very easily think that --mom died in the car accident because she was coming to get me or because the other driver was mad at her -- the person that shot my brother was shooting at me and hit my brother because he was in my room -- the fire was God's way of punishing (or martyring) my family. Be clear. Explore the child's evolving sense of causality. Correct and clarify as you see false reasoning develop. Over time, the ability of the child to cope is related to the ability of the child to understand, and while some elements of death and tragedy seem beyond understanding, this can be explained to a child -- some things we don't know. Don't let the child develop a sense that there is a secret about the event -- this can be very destructive. Let the child know that adults can not and will not understand some things either.
6. Surviving children often feel guilty.
A child surviving when family members die may often feel guilty. This can be a very destructive and pervasive belief. The amount of guilt a child feels may often be related to the degree to which they develop and maintain false assumptions about the event (see 4.).
An important principle in this process is that children do not know how to verbalize or express guilt in the same fashion as adults. Guilt, as expressed in children, may often be best observed in behaviors and emotions which are related to self-hatred and self-destruction. The child will likely not be able to articulate that survivor guilt is intimately related to their sense of worthlessness, self abusive or destructive behaviors.
The children surviving a parent's sudden death will have great survivor guilt. Was there something wrong or bad about me. I could have been there -- I should have been there. These thoughts will recur in any variety of permutations. And most of the time the outcome of these thoughts will be guilt. If these children's caretakers, therapists and teachers can minimize these potentially escalating and destructive ideas the chiid's recovery will be eased.
7. Distinguish between grief and mourning.
Grief is the label for the set of emotional, cognitive, behavioral and physical reactions that are seen following the death of a loved one. There are sets of normal responses which include denial, emotional numbing, anger, rage, rushes of anxiety (pangs), sadness, fear, confusion, difficulty sleeping, regression in children, 'stomach'. upset, loss of appetite, hysterical materializations (transient visual or auditory misperceptions that you have seen or heard the dead loved one) and many other potential symptoms. These symptoms are similar to those often seen in the acute post-traumatic period (see Appendix II).
Mourning is the formalized process of responding to the death. This includes memorial services, funerals, wakes, mourning dress and so forth. These semi-ritualized approaches are very useful in organizing and focusing the grief reaction in the immediate post-death period. It is important to allow children to participate in elements of this process. A major healing element of mourning is that it is one way in which someone can 'have control over' the way in which they experience a trauma. Rather than sitting alone with recurring intrusive thoughts about the death, one can, in a controlled fashion recall the lost one without focusing on the death event. The degree of control in coping with a traumatic event is very important in determining how destructive the event becomes over time (see Appendices II, lil and IV).
8. Grief is normal -- persisting grief reactions are not.
In the same way that a persisting presence of the acute reaction to trauma can signify major problems so can a persisting grief reaction. If symptoms listed above persist beyond 6 months or if the symptoms interfere with any aspect of functioning, they need to be addressed. If the child is in therapy, communicate this with the therapist. Find out if functioning in school is altered, watch for changes in patterns of play, loss of interest in activities -- be observant, be patient, be tolerant, be sympathetic. These children have been hurt and are in continuing pain.
9. Do not avoid the topic when the child brings it up.
Similar to the principles of dealing with other trauma, the adults around the child need to be available when the children want to talk but avoid probing when the children don't want to talk. This may mean answering one question -- it may mean struggling with a very difficult question 'Does it hurt when you burn to death ?'. Don't be surprised if in the middle of your struggle for the 'right' answer the child returns to play and acts disinterested. They have been unable to tolerate the level of emotional intensity and have avoided it in some adaptive fashion (see Appendix II).
Children will sense if the topic is emotionally difficult for adults around them.
The child will try to please the adults - either avoiding emotional topics or persisting with topics that they sense the adults find more pleasant. Try to gauge your own sense of discomfort and directly address this with the child. It is reassuring to the child that they are not alone in some of their emotional upset. Stay in control -- this is reassuring but verbal acknowledgment of sadness, hurt and anger by the adult can be important.
10. Be available, nurturing, reassuring and predictable.
Do your best to be available, loving, supportive and predictable. All of these things make the child's work easier. They feel safer and cared for. The loss of parents, siblings and other loved ones is extremely traumatic and will forever change these children's lives. The child has, in some sense, a life long task of working, re-working -- experiencing and reexperiencing the loss of these loved ones. Each holiday -- each 'family' occasion-- will bring the loss, the death and the ghost of the loved one to this child. Available, nurturing and caring caretakers, teachers, therapists and case workers will all make this journey easier.
11. Inform adults and children in the child's world what has happened.
Let teachers, counselors, parents of the child's friends and, if appropriate, the child's peers know some of the pain that this child is living with. Sometimes this can allow the people in the child's life to give them the small amount of tolerance or understanding or nurturing that will smooth the way. People can often be intolerant or callous when dealing with the pain of a grieving child " Isn't it about time they got over this ?" When you see that this is occurring don't be shy about taking this person aside and educating them.
12. Expect unusual 'sensory' experiences.
Over the six months following the loss, children (and adults) will often experience unusual visual, auditory or tactile sensations. A child may think they hear the person's voice -or they think they saw them in a crowd -- or out of the corner of their eye they may see their relection in a window. At bedtime or when awaking, these misperceptions are more common. They may be disturbing to parents, caretakers and the child. Reassure the child. These 'visions' are often interpreted in context of a religious belief system -- 'they came back to tell me it was ok-- they are still with me.' This can be important for the child and there is no reason to undermine these feelings. These 'hysterical materializations' are common and often mislabeled as visual or auditory 'hallucinations'. If you have questions about these symptoms contact an experienced mental health professional or physician.
13. Take advantage of other resources.
There are many other welltrained professionals willing to help you and the child in your care with these problems. Take advantage of them.. If the child is in therapy, talk to the therapist. Call our office we are always interested in helping the children. Always remember that this does not go away -- the way the child experiences it changes, evolves and matures. The loss of a parent, a sibling, a peer will always be with these children. Help them, over time with love and understanding, evolve a mature sense of this loss.