For most children, death is a new experience. And like all new experiences, the unknown can be confusing and frightening. Most children do not know what to expect following the loss of a family member or friend. Young children may not understand what death really means and may be confused or even frightened by the reactions of other family members. In the case of traumatic death, the confusion and fear is even greater.
For adults, death is more familiar and the grieving process is something many adults know first hand. Most adults have experienced the range of feelings that often come with traumatic loss - anger, confusion and sadness, and have learned ways to cope with loss. This may not be the case for children, particularly young children.
At the same time, children will seek answers and comfort from their caregivers and other adults in their lives. Yet in the face of traumatic death, adults often feel helpless in this role. While adults can not have answers to all the questions that children may have about death, they can help children better understand the grieving process.
This guide addresses some of the key issues related to the child's complex set of reactions that often follow traumatic death. While focused on traumatic death, this information may be helpful to families, caseworkers, 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 to be comprehensive or to exclude other observations or approaches to helping grieving children.
Don't 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 adults around her are upset about the event, she may not bring it up even if she wants to. In traumatic death, there are two central challenges for the child: processing the actual traumatic event (e.g., the shooting, the accident, the fire), and coping with loss of the loved one. In the immediate post-traumatic period, the child's thoughts will be dominated by the terrorizing event. The loss of the loved one looms as a shadow in these first weeks. Over time, however, the child's thoughts and feelings will be dominated by loss. The primary emotion of the first phase is fear; the primary emotion of the second is sadness.
In the long run, without freely talking about the loss or expressing sadness, anger and confusion, the child's recovery will be more difficult. Children model their emotional expression and behavior after their caregivers. It can be very helpful for a child to know that adults feel sad, too, and for you to share with them how you cope with in your own life. Over time, helping the child keep part of the loved one with them in memories, rituals, habits, beliefs, and behaviors can be very useful. The formal mourning rituals and beliefs of the child's culture or religion can be very helpful as well.
With that said, in traumatic death, especially if the child was a witness to the traumatic event, until the child can cope somewhat with the traumatic event, their capacity to mourn the loved one can be impaired. That is why it is not only ok to talk about the traumatic event, it is critical for the child long-term recovery of the child. The central issue becomes how you talk about it.
In the first few days or weeks following the trauma, caregivers should sit down with the child and tell them how it is very normal to think about the traumatic event. Adults should share some of their feelings and thoughts about the event as well. When discussing this issue with children, be sure to use age-appropriate language and explanations. The timing and language used are important. The child will very likely be very quiet. Don't worry about that. Immediately following the death, the child will not be very capable of processing complex or abstract information. Invite them to come and talk about it anytime they want. And from then on, let the child take the lead as to when, how long, and how much you talk with them about the trauma. Each child will have a different style of coping - some children will not talk much, some will talk about it to strangers. It is not unusual for a six-year-old to announce to her new kindergarten teacher, "My mother got shot." And it may not be unusual for a 15-year-old boy to never talk to any adults about the traumatic murder of his brother.
As the child gets further away from the event, she will be able to focus longer, digest more, and make more sense of what has happened. Don't be surprised if the child even acts as if the loved one is not dead or that "Mommy" will be coming back. Sometimes young children act as if they have not 'heard' anything you have said. It takes many individual moments of sad clarity for the reality of the loss to actually sink in for young children. Between these moments of harsh reality, children use a variety of coping techniques - some of which can be confusing or upsetting for adults.
Listen to the child, answer their as best you can. As you answer you can provide comfort and support. We often have no adequate explanations about senseless or traumatic death; it is just fine to tell children that you do not know why something happened or that you get confused and upset by it, too. In the end, listening and comforting a child without avoiding or over-reacting will have critical and long-lasting positive effects on the child's ability to cope with traumatic loss.
During this long process, the child continues to 're-experience' the loss. In play, drawing and words, the child may repeat, re-enact and re-live some elements of the traumatic loss. Surviving adults will hear children ask the same questions again and again. In addition, the child may develop profound "empathic" concerns for others experiencing loss, including cartoon characters and animals - "Where is Mickey Mouse's mother?" Or seeing a dead bird they may ask, "Who is taking care of the baby birds now?"
The child will experience and process the very same material differently at various times following the death. In the long run, the opportunity to process and re-process many times will facilitate healthy coping. This re-processing may take place throughout a given child's development. Even years after the death of a mother or a sibling, a child may 'revisit' the loss and struggle to understand it from their current developmental perspective.
One of the most important elements in this process is that children of different ages have different styles of adapting, and different abilities to understand abstract concepts such as death. Children at different ages have very different concepts of death; for example, very young children may have little appreciation of the finality of death. Be sure not to associate sleep and death. When these two become associated, it is not surprising that children become afraid of sleep. Children may become afraid of loved ones going to sleep. Try to get some understanding from the child of what she thinks death is - does she 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 in a meaningful fashion.
Yes. If you and the child's caregivers feel it's appropriate, you can help to inform adults and children in the child's world what has happened. Let other 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. In some cases, older children can benefit by participating in this process. Sometimes this can help the people in the child's life be more patient, understanding or nurturing. People can often be intolerant or insensitive when dealing with the pain of a grieving child, sometimes asking, "Isn't it about time he got over this?" When you see that this is occurring, don't be shy about taking this person aside and helping him understand what the child is going through.
Grief is the label for the set of emotional, cognitive, behavioral and physical reactions that are seen following the death of a loved one. Normal grief responses may 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 of the loved one's image or voice) and many other potential symptoms. These symptoms are similar to those often seen in the acute post-traumatic period.
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 allows the grieving person to "have control over" the way in trauma and loss are experienced. 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.
While grief is normal, persisting grief reactions are not. In the same way that a persisting acute reaction to trauma can signify major problems, so can persisting grief reactions. If the symptoms listed above last for six months or longer, or if the symptoms interfere with any aspect of functioning, they need to be addressed. If the child is in therapy, caregivers should communicate this with her therapist. You can also let the child's caregivers know whether school performance has been affected. Watch for changes in patterns of play and loss of interest in activities. Be observant. Be patient. Be tolerant. Be sympathetic. These children have been hurt and are in continuing pain.
Expect unusual "sensory" experiences. During the first six months following the loss, children (and adults) will often experience unusual visual, auditory, or tactile sensations. A child may think she hears her dead mother's voice in the next room; she may catch a glimpse of her mother in a crowded mall; out of the corner of her eye, the child may catch mother's reflection in a window. At bedtime or upon waking, these misperceptions are more common. They may be disturbing to parents, caregivers, and the child. Reassure the child. These 'visions' are often interpreted in context of a religious belief system - "Mommy came back to tell me it was okay; she is 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, discuss them with an experienced mental health professional or physician. It may also be helpful to speak directly with the child's caregivers about what is happening.
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: someone dies in a car accident, is killed in a drive-by shooting, or dies in a fire. The child, however, may very easily distort an event, and come to the wrong conclusions about causality. "Mom died in the car accident because she was coming to get me at school. The other driver was mad at her;" "My brother is dead because he was helping me with my homework. The person that shot my brother was really shooting at me, and hit my brother because he was in my room." "The fire was God's way of punishing (or making an example of) my family." In many of these distorted explanations, children assume some degree of responsibility for the death. This can lead to very destructive and inappropriate feelings of guilt. Try to correct any misperceptions immediately. And be prepared to correct these false, destructive ideas again and again.
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. While some elements of death and tragedy will always remain beyond understanding, explain this to the child: "I don't know, some things we can never really understand." If the child feels that they share the unknown and unknowable with an adult, they feel safer. 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 cannot and will not understand some things either.
In summary, there are a number of important things you can do as a prominent figure in a child's life to help him cope with the loss he has suffered.
1. Be honest, open and clear. Whenever possible, adults should give children the facts regarding the death. While there is no need to describe great lingering detail, the important details should be given. These may be horrifying, but it is always 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 ultimately interfere with the long-term healing process.
2. Do not avoid the topic when the child brings it up. Similar to other trauma, the adults around the child need to be available when the child wants to talk, but should avoid probing when the child does not want to talk. This may mean answering one question, or 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. The child has been unable to tolerate the level of emotional intensity and are coping with it by avoiding it at that point.
Children will sense if the topic is emotionally difficult for adults around them. A child will try to please adults by either avoiding emotional topics or persisting with topics that she senses they find more pleasant. Try to gauge your own sense of discomfort and directly address this with the child. It is reassuring to children that they are not alone in some of their emotional upset.
Children look to adults to understand and interpret their own inner states. Younger children will even mirror the nature and intensity of an adult's emotions. So if you feel you will be unable to control your emotions when you are trying to help the child, you will need to use some coping strategies yourself. Take a few moments, collect yourself and then try to help the child. It is only human to lose control and be very emotional in these moments. After you feel more composed, you can help the child understand how you were overcome with emotion, "Just like you feel sometimes." Explain that you struggle to understand too - that "We need to help each other when we are sad."
3. Be prepared to discuss the same details again and again. Expect to hear things from the child that seem as if they didn't "hear" you when you told them the first time. The powerful, pervasive implications of death for the child can be overwhelming indeed. 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 (e.g., the future), helplessness, and confusion.
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 over and over again. As they do, the child (if she feels safe and supported by the adults around her) 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 - or 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, and help the child understand that you and others can and do live with many unknowns. In this process, let the child know, however, that there are things we do know - things we can understand. Bring positive memories, images and recollections of the loved one into the conversation.
4. Be available, nurturing, reassuring, and predictable. All of these things make the child's work easier. She feels safe 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 lifelong task of working, re-working - experiencing and re-experiencing 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 caregivers, teachers, therapists, and caseworkers will all make this journey easier.
5. Understand that 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 guilt children feel is related to the false assumptions they make about the event. 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 by children, may often be best observed in behaviors and emotions that are related to self-hatred and self-destruction. The child will not likely be able to articulate that survivor guilt is intimately related to their sense of worthlessness or self-abusive/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 caregivers, teachers, and therapists can minimize these potentially escalating and destructive ideas, the child's recovery will be eased.
6. Take advantage of other resources. There are many other well-trained professionals willing to help you and the child in your care with these problems. Take advantage of them. Always remember that the loss does not go away, but the way children experience loss will change with time, hopefully maturing in ways that make it easier to bear. The traumatic loss of a parent, a sibling, and a peer will always be with these children. With time, love, and understanding, however, children can learn to carry the burdens of traumatic loss in ways that will not interfere with their healthy development.
Dr. Bruce D. Perry, M.D., Ph.D., is an internationally recognized authority on brain development and children in crisis. Dr. Perry leads the ChildTrauma Academy, a pioneering center providing service, research and training in the area of child maltreatment (http://www.childtrauma.org/). In addition he is the Medical Director for Provincial Programs in Children's Mental Health for Alberta, Canada. Dr. Perry served as consultant on many high-profile incidents involving traumatized children, including the Columbine High School shootings in Littleton, Colorado; the Oklahoma City Bombing; and the Branch Davidian siege. His clinical research and practice focuses on traumatized children-examining the long-term effects of trauma in children, adolescents and adults. Dr. Perry's work has been instrumental in describing how traumatic events in childhood change the biology of the brain. The author of more than 200 journal articles, book chapters, and scientific proceedings and is the recipient of a variety of professional awards.
Jana Rubenstein, M.Ed., LPC is the Director of the ChildTrauma Academy, a partnership between Texas Children's Hospital and Baylor College of Medicine which aims to improve the systems that educate, nurture, protect and enrich children. Ms. Rubenstein has extensive clinical experience working with children and families dealing with trauma and loss.
Bruce D. Perry, M.D., Ph.D., is the Thomas S. Trammell Research Professor of Child Psychiatry, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; and Chief of Psychiatry, Texas Children's Hospital, Houston, Texas.