Children Adolescents Grief and Trauma Kenneth J Doka

Children, Adolescents, Grief, and Trauma Kenneth J. Doka, Ph. D Professor, The College of New Rochelle Senior Consultant, The Hospice Foundation of America

Four Goals l To review how concepts of death change throughout the life cycle l To explore the ways that children and adolescents experience loss l To discuss strategies to assist children and adolescents l To examine the particular issues raised by traumatic loss

Developmental Perspectives on Death

The Kingdom Where Nobody Dies l The myth of children and loss

Children Historically Dealt with Death and Loss l l l Fairy Tales Games Books and Stories Jokes Songs

Children Are Constantly Exposed to Loss and Death Television l Music l News l Experience l

Yet, Children Are Constantly Developing Cognitively l Emotionally l Socially l Spiritually l

Young Children Animistic l Artificialistic l Blur boundaries between life and death l Yet, “all gone” an early concept l

Children Develop in Their Cognitive Mastery of Death l Conceptualizing Death – Universality – Nonfunctionality – Irreversibility – Causality – Continuation

Young Children Have a Short Feeling Span They can sustain intense emotions for a short time (Crenshaw) l Implications for counseling l

Children Develop Socially Cooley’s Play and Game Stage l The Development of Empathy l

Children as Spiritual Pioneers R. Coles, The Spiritual Lives of Children

Discussing Death with Children l l l Always make sure you know the question the child is asking and the context (Why is the question being asked now? ) Be honest but reassuring Keep the dialog open Ask for feedback Share faith and feelings

Development Continues Through Adolescence l Young l Middle l Old

Death is a Significant Undercurrent Adolescence l l l The Three “I’s” – Independence, Identity, Intimacy Time of critical evaluation Significant separations Problematic experiences of death Defended against by present orientation

Loss and Grief in Children and Adolescence

Children Are Embedded in Webs of Relationships l l l l Family Friends Neighbors Teachers Coaches School Faith Communities

Children Experience Many Losses l Death l Divorce l Separation l Loss of Dreams l Relocation

Some Losses May Be Catastrophic l Abandonment l Foster Care Placement l Fire, Disaster l Homelessness, Eviction, Rapid Relocation

At What Age Can Children Mourn? With object constancy (around 3 years-old) l Only with adolescent development of identity l

Worden’s Answer Children mourn at any age – but different from adults

My Comment Children mourn at any age – but different from and similar to adults

Grief May Be Manifested in Many Ways – Similar to Adults l Physically l Emotionally l Cognitively l Spiritually l Behaviorally

Manifestations of Grief How sees homesick kids first? l Children are prone to somatically display their grief reactions l – Misinterpret physical manifestations of affect – Care eliciting l Assess physical reactions such as aches and pains – persistent complaints should be treated

Manifestations of Grief l l l Emotionally children may have similar reactions to adults Sadness Fears and anxieties Guilt and magical thinking Anger and the lack of control Other emotions

Manifestations of Grief l l l Grief affects children and adults cognitively Depersonalization and denial Problems with concentration, lack of focus, impaired thought Many of the manifestations of grief can mimic learning disabilities Importance of loss inventory

Manifestations of Grief Children may react behaviorally – in many of the same ways as adults – avoiding or seeking reminders, withdrawal, crying l And spiritually – struggling with doubts, anger, or spiritual questions l

Continuing Bonds l l l Memories Biography Legacies and liabilities Spiritually Extraordinary Experiences (La. Grand)

The Grief Process A Roller Coaster of Reactions

Stroebe and Schut Dual Process Model l Calls for Oscillation between – Loss-Oriented Processes – Restoration Processes

Grief is not a time-bound process that ends in detachment

Amelioration of Grief l Over time pain lessens l Persons function at similar (or sometimes better levels) than prior to the loss l Yet, grief still has a developmental aspect

Yet, there also differences To Bowlby early loss may impair trust and create attachment issues throughout life – (perhaps mitigated by continuity, story) l Crenshaw and the crisis of impending connection l

Other Differences Manifestations may include acting out, sleep disturbances, regressive behaviors, accidents, changes in behavior or grades l Children may re-grieve earlier losses l

Children and Adolescent Grief Thus children and adolescents may experience periods of grief throughout the life-cycle l In early loss, the re-grief phenomenon l As they struggle with identity l Developmental surges

Grief takes place in a family context The Harvard Bereavement Study isolated a number of risk factors for both the child and the family. Yet, these are best summarized as the best predictor of the child’s adjustment is the ability of the surviving parent to function.

The Issue of Trauma Grief and Loss l The Loss of an Assumptive World l Mistrust and Anxiety l Resonating Trauma (Rumor and the restoration of the assumptive world) l

The Damocles Syndrome Koocher ‘s et al study of children who survived childhood cancer felt a heightened sense of mortality throughout their lives This heightened sense of mortality was labeled the Damocles Syndrome May be present for children who survive or witness a traumatic Event

Adolescents Often Experience Difficulty as They Grief l Discomfort with differences l Ability to seek support from adults l Limits to peer support l Time of spiritual questioning

Adolescent Grief l l l Acting Out (including behaviors, substance abuse, sexual, eating disorders) School Performance Changes – Yet, Note Development Self-Esteem Anxiety

Adolescent Grief The Internet as Support Technology as difference l Adolescents as Digital Natives (rather than Digital Immigrants) l 93 % use the Internet, 79 % of 15 -17 year-olds have cell phones l Prevalence of My. Space and Facebook l

Adolescents and the Internet The Internet allows experimentation with different personas l Internet relationships can offer a sense of belonging l The Internet can offer the possibility of validation without risk l The Internet offers information independent of asking adults l

Adolescent Grief The Internet as Support The Internet offers information about grief l There are opportunities to memorialize online l One can express grief to peers and others in blogs l One can offer and receive support including in online support groups l

The Internet and Adolescent Grief Support Dangers! l l l Information may not be accurate Support groups may lack professional supervision and even be unsupportive Comments by others can be hateful, harmful, or denigrating The danger of vulnerable adolescents and online predators Internet options may make the adolescent less available for more suitable and qualified assistance

The Internet and Adolescent Grief Support Points for the Counselor 1. Ask adolescents about the Internet and if and how they are using it as they cope with their grief 2. Create an ongoing dialogue about their Internet use

Disenfranchised Grief Sensitivity to Online Relationships l Chat Room Relationships l Participants in massively multiplayer online role-playing game (MMORPG) l The funeral of Toxik/Chris l

Schools Can Play a Critical Role l l l Academic Social and Developmental Arena Sources of Formal and Informal Support “Early Warning” System Links Families

Assisting the Grieving Student l Acknowledge loss l Understand grief l Offer support (including groups) l Empower natural networks l Recognize developmental needs l Problem solve l Sensitivity with Projects/Events

Assisting the Class l l l Open communication Prepare (with parents) class for possible changes Empower peer support and deal with class affect Have school nurse explain illness and address any questions or anxieties Assist teachers If appropriate inform other parents

The Letter Home Privacy and permission with illness – check with parents l Send – not with a child (note in some districts email can work – or a phone alert that a letter is coming with the child) l Contents l – What happened – How the school responded – What your child may experience – Available sources of help

When a Student Dies (or other school-related death) l l l Information chain (VERIFY!) Inform students Encourage discussion Provide support and counseling (and identify at risk) Allow students to self-select into counseling as well Encourage and empower outreach Shape group response Inform parents Remove papers in normal cycle Automatic communications? (PTA notices etc) Support staff

How can we help children and adolescents adapt to loss?

General Principles l Sensitivity l Validation to Loss

Communicating with Children What can they understand? l What do they want to know? l What do they need to know? l

Empower Families Children’s Grief Takes Place in a Family Context l Assess Rules and Communication l Risk Factor – Parental Functioning l Note Extended Family/ Intimate Networks l

Parents Can Help l Assess their functioning and the functioning of the child l Assess their messages to the child l Allow and validate grief l Encourage support l Encourage ritual

Illustration: Children and Funerals Importance of Ritual – including Spiritual l Value of Personalization and Participation l Choice l – Information – Options – Support

Effective Support for Children The Value of Family Centered Counseling l Provide Support for Parents – Process their grief – Skill-building including teaching them how to assist their children with secondary loss l Provide Support for Children – Grief support – Adjusting to a new life

Tripartite Assessment (Webb) l Individual Factors l Loss-Related Factors l Socio-Cultural Factors

Individual Factors l l l Age/developmental level Past coping Global assessment Medical history Past loss experience

Medical History Check on use of psychotropic drugs as this is the most medicated generation in history l The role of psychotropic drugs such as Ritalin is yet unknown but certainly may distort the experience of grief l Remember that grief and some learning disabilities share common manifestations l

Medical History With adolescents assess (non-judgmentally) alcohol and drug use l Depending on age and initial assessment, this can be done as an “assumptive fact” – How often do you drink beer? l Drug and alcohol use can be a problematic way to cope with loss and even constitute a pattern of “masked grief” l

Loss-Related Factors Relationship l Type and circumstance of loss l Grief reactions l

Socio-Cultural Factors l l l Nuclear and extended family Social support Peer support Culture Religion/Spirituality

The Tasks of Grief l Acknowledge the loss l Express manifest and latent emotion l Adjust to a changed life l Relocate the loss l Reconstitute faith and philosophical systems challenged by the loss Worden (Modified)

The Work of Children is Play (Webb) l The Value of Expressive Approaches – Natural – Reflective – Cathartic – Projective l Be Prescriptive

The Tasks of Grief Acknowledge the Loss l l l l Barriers Cognitive understanding Adult protectiveness Unclear language Limited experience Strategies Value of clear language and open communication Supported visits (hospitals etc. ) Presence at rituals Drawing or acting out events

The Tasks of Grief Express Manifest and Latent Emotion l l l l Barriers Short feeling span of young children and limited vocabulary Protecting parents Adolescent defensiveness Strategies Five faces, feeling games and feeling checks Expressive approaches Connecting feelings and actions Assess self-blame and unrealistic thinking

The Tasks of Grief Express Manifest and Latent Emotion Two Critical Issues l Ambivalence – Understanding ambivalence – Secondary gains – Powerlessness of children l Finishing Business – Definition – Approaches

The Tasks of Grief Adjust to a Changed Life l l l Barriers Lack of control over changes Cognitive understandings (with young children) Strategies Empower communication between parents and children Emphasize the value of true choice Anticipate difficult days A magic wand

The Magic Wand An effective way to assess children and adolescent thinking and fantasies l If you had a magic wand, what would you change? l How would that make you and your life different? l

Inner Representation and Relocation When a child dies, Klass reminds that parents and children carry an inner representation of the child l Very aware of how old the child would be now and carrying an image of the child’s appearance or of how the child would be l Excessive idealization may negatively affect surviving children l

The Tasks of Grief Relocate the Loss l l l Barriers Short feeling and attention spans of young children Protection of parent Family rules Strategies Timelines and life histories Memory books, albums, and boxes (note social class implications)

Adolescent Memorializing Adolescents may have special ways of memorializing Wall Memorials, graffiti l RIP Tattoos, Body Art l RIP tee shirts or other clothes l Memorial Blogs or Site l Auto Markings l Memorial Jewelry Barrett, 2009 l

The Tasks of Grief Reconstitute Faith and Beliefs Challenged by Loss l l l Barriers Children as spiritual pioneers Adolescent questioning Strategies Empower parents and other adults to share how their beliefs help them in this loss Spiritual stories Explore and validate loss of assumptive world (meaning – making strategies)

Expressive Approaches l l l l Art Movement/Drama/ Role Play Crafts Storytelling/Poetry/ Creative Writing Photography/Videos Music/Dance Games

Corr’s Guidelines for Bibliotherapy Read and evaluate the book l Select appropriate title for capability and context l Cope with limitations l Discuss with child l

The Value of Therapeutic Ritual l Liminal l Bridge to Spirituality and Culture l Family Centered l The Value of “Doing”

Types of Ritual l Continuity

Types of Ritual l Transition

Types of Ritual l Reconciliation

Types of Ritual l Affirmation

Creating Ritual Arise from narrative l Objects are visible and symbolic l Planned and processed l Use primal elements (Fry) l

The Possibility of Group Ritual Arise from collective experience l Participants allowed to “own “ the ritual l

Grief Groups

Support Groups l Validation l Ventilation l Respite and Support l Learn Coping Techniques

Grief Groups for Children l Reason l Size l Developmental issues l Leaders and co-leaders l Time issues - School Calendar l Intake l Open or close-ended

Grief Groups - Content Should not focus solely on emotions l Other topic l – – – Opening/closing – rules and ritual Processing the experience – illness, death, funeral Coping and support Memories Lessons learned Sensitive to class and cultural issues l The value of “doing” – projects l Empowering families through workbooks and handouts l

Grief Camps Bonding and Support l Problems l – Homesickness – Discipline – Love triangles

Suicide in Children and Adolescents

Understanding Suicidal Behaviors Ideation (Relatively Common) l Gestures l Attempts l Completions l

Suicide Rate l Under-estimated especially in children and adolescents l Difference between suicide attempt and completed suicide l Risky and Self-Destructive Behaviors

The Suicide Rate Rises in Adolescence l Biochemical l Social and Psychological Stresses of Puberty l The Organization of Middle School l Social and Cultural changes

Adolescent Suicide Three Roles 1. Prevention 2. Intervention 3. Postvention

Multiple risk factors make prediction of suicide difficult

Adolescent Suicide Risk Factors l l l l Poor family life Poor problem-solving and coping skills Special education at risk Academic problems – including perceived Emotional problems Substance abuse Neglects appearance l l l l History of accidents or self -destructive behaviors Sexuality issues and fears Less school involvement Less active peer life Bullied Abused physically or sexually Low self-esteem Catastrophic loss

Types of Suicide l l l l l Psychotic Depressive Crisis Anomic Egotistic Altruistic (Rare) Fatalistic Murder/Suicide Autoerotic “suicide”

The Value of a Shared Protocol for Intervention

The Value of a Shared Protocol Training in the protocol should include all school staff l Children may relate well and share with adults not perceived to be in authority l

Assessing Risk CPR+ l Current Suicidal Plan l Prior Suicidal Behavior l Resources (Support) Available + l Signs l Stressors

The Interview l l l Find a quiet place to talk Ask directly about suicidal plans and thoughts – open-ended questions Focus carefully on the problems – listen actively Assess risk Discuss strategies for dealing with the problem including parental contact, hospitalization Mobilize the adolescent’s resources – clergy, parents, etc.

The Interview (2) l l l l Stay with the adolescent Foster hope Reach a contract and a plan Follow up Beware of the “Flight to health” Avoid moralizing, scolding, ‘reverse” psychology, attempts to provoke Share with colleagues and supervisor – do not work alone

Assessing Risk Questions l On a scale of 1 to 10, how have you been feeling lately? l Assess changes in appearance, sleep, appetite. l Do you ever think of killing or hurting yourself? When? How often? What would you do? Are you currently thinking of killing yourself?

Assessing Risk Questions (2) l l l Do you have a suicide plan? What is it? (Assess how realistic it is. ) On a scale of 1 to 10, how likely is it that you would kill yourself? (Danger of 5+) Do you know anyone who has killed or attempted or completed a suicide? What are you looking forward to? (Assess hope) Assess resources

Intervention: A Summation l Assess Risk l Decide Intervention Strategies l Referral (as related to strategy – if hospitalization, process experience with student – likely experience etc. ) l Notify Appropriate Persons l “Hand-off” Student l Follow-up with Staff, Student (if so referred) l Follow up with Student (at return)

Suicide Postvention l l l Importance – The Cluster Effect Communication Chain – Inform Staff Media Plan Inform Students Review Life and Death (Avoid Scapegoating) Identify those “At-Risk” Set Up Counseling Remember Staff “Careful” Memorializing Inform Parents Monitor the Internet

Suicide Prevention The best prevention may never mention suicide Strategies for Schools l Curriculum Review l Teach Problem. Solving and Coping Skills l Enhance Self-Esteem Traditional Approaches

Violence and Tragedy

Violence in Children and Adolescents l l l l Social (media, availability of weapons, social status) Cultural Psychological Lessened Family Supervision Spiritual Technology (Violent Video Games, Internet, Cyber-bullying) The Socialization of Males

Reducing Violence in Schools l l l l Zero Tolerance and “True Threat” Zero tolerance vs. progressive discipline Staff Training Conflict Resolution Anti-bullying programs Supervision and policing Bolstering community (peer-centered programs)

Creating School Community Teach acceptance rather than tolerance l The importance of adult modeling l Issues of size and organization l

Violent Events Importance to have a “lock -down” and evacuation procedures along with regular drills l There is value in educating staff in creating a false “all clear” signal in case the administrator is under duress l Staff need to differentiate between true and false signals l

Helping Children Cope with Tragedy Principles that Need to Be Applied According to Developmental Level l l l l Acknowledge fear and other responses Offer honest reassurance Physical closeness (hugs, presence) Keep communications open Monitor media and Internet Empower actions The value of maintaining viable routines Watch for danger signs and refer when necessary Care for the carers!

Good Advice for Adults Too!

School Responses to Traumatic Loss l l l l l Communication Chain – Inform Staff Media Plan and Spokesperson Inform Students Validate and Explore Responses Identify those “At-Risk” Set Up Counseling Remember Staff Shape Group Response Stakeholders and memorialization Inform Parents

School Memorials Lessons from Columbine l l l It is a time-consuming process – allow time for consensus and compromise Columbine opened the committee to all In public space, need to have policies to cover the use of religious, political, or potentially offensive statements Memorial placed so it could be visited rather than confronted Columbine used a “pyramid” of priorities in evaluating designs – – Families of the those killed Injured and families Students and faculty Community In another memorial, issue of perpetrators Bingham et. al. , 2009 l

Debriefing After events, it is important to debrief the incident with crises staff, guidance, and key administrators l Were procedures followed? How did the protocol work? What lessons were learned? What should be done differently? l Protocols also should be reviewed at the beginning of the year l

After the Crisis l Monitor those who witnessed the event for PTSD l Remember PTSD needs treating by specialists