Holly Herring, MS, APRN Director, Children and Family Support Services

1. Empowering Bereaved Caregivers to Facilitate the Grief Process with Children Holly Herring, MS, APRNDirector, Children and Family Support Services

2. Objectives At the conclusion of this presentation, participants will be able to: • Describe common grief reactions in children, with special focus on the effects of grief on the family system • Identify three ways in which parents can facilitate the grieving process among all family members • Discuss three interventions for use by parents or professionals working with grieving children

3. Children and Grief

4. Every child grieves differently Individual and cultural factors will influence grief response Common responses based on age and developmental stage What Does Grief Look Like in Children?

5. The Grief Process Can begin before the death There is no “getting over” a loss Not orderly or predictable Everyone grieves in their own way and in their own time Some common tasks in grief work Goal of grief work: integration (living with the loss)

6. Forces the creation of a “new normal” Family members must often adopt new roles and assume new responsibilities “Mobile” as analogy Family system striving for homeostasis Loss Changes the Family System

7. Siblings: The Voice of the Invisible • Perceived their life has changed • Sense the previous family dynamic has been altered • Experience intense feelings • Seek open communication and involvement in care of sick brother or sister • Desire to feel recognized Kreicbergs, U. The Voice of the Invisible – the experience and consequences of having a brother or sister with cancer during childhood.

8. Grief in Children Children do not grieve continuously – they take breaks Grief behaviors may be mixed with play Understanding of death is limited to their cognitive development Young children may not retain an image of the deceased Children are generally dependent upon adults for support, may not be able to articulate their needs Grief in Adults Adults grieve fairly constantly and are usually not delayed Adults typically separate grief from play Adults are aware of the irreversibility of death. Adult memory of the deceased is more fully developed Adults can seek help and are usually able to meet their needs independently. Jeffreys (2005), p. 96 How Does Grief Differ in Children and Adults?

9. Parent as Griever, Parent as Facilitator

10. Modeling Good Grief • Children usually take the lead on grieving from their parents • Parents don’t need to hide their grief • Open communication • Sharing thoughts and feelings

11. Helpful Tips for Parents • Don’t feel that you must have the correct answers. • Invite your children to offer their own musings about their questions. • Don’t be afraid to say, “I don’t know.” Tedeschi & Calhoun (2004), p. 94

12. Working with Grieving Families

13. General Grief Interventions “Expert companionship” Tedeschi & Calhoun (2004), p. 38 The gift of being present Active listening, touch, silence, reassurance Normalize & individualize the grief process Actualize the loss & facilitate living without the deceased Identify support systems Utilize community resources

14. Grief Interventions for Children Provide age-appropriate information Address fears, answer questions Offer opportunities to grieve Not all children grieve through talking Art, music, play Listen, validate feelings, and provide reassurance Include in funeral/memorial to the extent child desires Continue routines as much as possible Children appreciate consistency – offers safety, return to “normal”

15. Grief Interventions for Families • Creating a remembrance ritual • Each family member can play a role • Can be repeated on special days • Schedule family time (“Family night”) • Time for fun and relaxation • This may take practice

16. Research and Literature • Research has found that Art as therapy: • Can help gain insight, develop creative skills, and enhance self esteem. • Has the potential to be more effective at reducing stress and anxiety than other methods. • Can help “suspend their inner dialogue” and interrupt the cycle of negative thoughts • Can tap “into the unconscious giving concrete form to feelings of which individuals are usually unaware.” (Devlin, 2006)

17. Car Toolkit • Crayons and Markers • Paper or Sketch Pad • Scissors • Glue • String • Deck of Cards • Stickers • Play-dough

18. Blank Paper • Free Drawing • Draw a person • Draw a bridge • Draw a house • Draw a person in the rain • Draw pain or fear • Safe Place Drawing • Draw a place where you feel safe • Can be useful for guided imagery and relaxation

19. Involving Children in Grief Work • Messengers of Hope • Bird feeder outside of office • Imagine birds as messengers • Balloon message • Prayer or Wish Tree • Prayers or wishes written, laminated and tied to a tree • Spiritual Bracelets • Choose colors that represent forgiveness, faith, courage, hope, love or… • Choose the values you need or want to develop • Dream Catcher

20. Art Activities • Mandalas • Circular drawing that can be used to assess or as non-threatening treatment • The circle is thought to represent the wholeness of the person or experience • Useful as a group opening or for closing • Useful tool to distract guarded children during difficult conversations From Creating Mandalas.com http://www.creatingmandalas.com/index.html

21. In conclusion… • Just as every family is different, each family and family member will grieve differently • Parental grief does not need to be hidden, and can be a useful tool in helping children with their grief • Bereavement professionals can help parents and families navigate through the grief process

22. Bibliography • Davies, B., Attig, T., & Towne, M. (2006). Bereavement. In A. Goldman, R. Hain, & S. Liben (Eds.), Oxford textbook of pediatric palliative care. New York, NY: Oxford University Press. • Davies, B. & Jin, J. (2006). Grief and bereavement in pediatric palliative care. In B.R. Ferrell, & N. Coyle (Eds.), Textbook of palliative nursing (2nd ed., pp. 975-989). New York, NY: Oxford University Press. • Davies, B., & Orloff, S. (2004). Bereavement issues and staff support. In D. Doyle, G. Hanks, N.I. Cherny, & K. Calman (Eds.), Oxford textbook of palliative medicine (3rd ed., pp. 831-839). Oxford, UK: Oxford University Press. • Gibbons, M.B. (2009). Psychosocial aspects of serious illness in children and their families across settings. In A. Armstrong-Dailey & S. Zarbock (Eds.), Hospice care for children, 3rd edition. New Yor, NY: Oxford University Press. • Jeffreys, J.S. (2005). Helping Grieving People: When tears are not enough. New York, NY: Brunner-Routledge.

23. Bibliography • Martin, T. & Doka, K.J. (1999). Men Don’t Cry, Women Do: Transcending Gender Stereotypes of Grief. Philadelphia: Taylor & Francis. • Midland, D., Gensch, B., & Rybarik, F. (Eds.). (2004).  RTS Bereavement Training in Pregnancy Loss & Newborn Death (6th ed.).  La Crosse, WI: Gunderson Lutheran Medical Foundation. • Oliver, L.E. (1999). Effects of a child’s death on the marital relationship: A review. Omega, 39, 197-227. • Parkes, C.M., & Prigerson, H. (2009). Bereavement: Studies of grief in adult life (4th ed.). New York, NY: Routledge. • Silverman, P. R., & Kelly, M. (2009). A Parent’s Guide to Raising Grieving Children. New York, NY: Oxford University Press. • Tedeschi, R. G., & Calhoun, L. G. (2004). Helping Bereaved Parents: A Clinician’s Guide. New York, NY: Brunner-Routledge. • Worden, J.W., & Monahan, J. R. (2009). Caring for bereaved parents. In A. Armstrong-Dailey & S. Zarbock (Eds.), Hospice care for children (3rd ed). New York, NY.: Oxford University Press.

24. Bibliography • Kreicbergs, U. The voice of the invisible – the experience and consequences of having a brother or sister with cancer during childhood. International Society of Paediatric Oncology. Retrieved on 4/4/2011 from: https://www.cure4kids.org/private/courses_documents/m_382/Voice-Invisible-Brother-Sister-Cancer.pdf • Remke, S. R. (2011). Pediatric Workshop. Children’s Hospitals and Clnics of Minnesota. Pain and Palliative Care. • Roush, K. (2006). I wish I had understood what it meant, leaving you that last time. American Journal of Nursing, 109 (9); 77. • Wolfe J, Hammel JF, Edwards KE, Duncan J, Comeau M, Breyer J, Aldridge S, Grier HE, Berde C, Dussel V, Weeks JC. Easing of Suffering in Children With Cancer at the End of Life: Is Care Changing?. Journal of Clinical Oncology, 2008;26(10):1717-1723.