Supporting Children When Someone in the Family Dies

1. Supporting Children When Someone in the Family Dies Julia Samuel Founder Patron & Trustee

2. Factors affecting the grieving process

3. Situational Stress Factors • Witnessing or hearing the death • Manner of death • Circumstances surrounding the death • Conflict between relatives • The police investigation • Powerlessness • Cultural and spiritual factors

4. Circumstances of death/dying Relationship with person who died ‘Recovery’ environment Ourselves, personality, background Factors affecting the grieving process

5. Children and Young People Physical & Mental Health • Bereaved children visited their GP more frequently (1998 Lloyd Williams, M. & Wilkinson, C.) • Bereaved children were found to be more likely to develop symptoms such as headaches, stomach aches (1996 Worden, W.) • Between 50-66% bereaved children show distress and depressive symptoms which may persist over time (2006Ribbons McLardy, J.)

6. Traumatic Bereavement

7. Definition of Trauma The person’s response involved intense fear, helplessness or horror (In children this may be expressed instead by disorganised or agitated behaviour) Criterion A2 of DSM-IV-TR PTSD

8. There is evidence to suggest that traumatic memory is encoded in the brain in a different way than non-traumatic memory

9. Sight Smell Sound Fear Network Feeling Taste Touch Physiological Thought © David Trickey

10. Memory or thought suppressed or avoided Maintenance Cycle of Avoidance Memory not processed Intrusions e.g. memories, images, dreams, thoughts Original fear, horror, helplessness © David Trickey

11. Common reactions after a frightening event • Nightmares • Memories or pictures of the event unexpectedly popping into the mind • Feeling as if it is actually happening again • Not wanting to think or talk about the event • Avoiding anything that might remind them of the event

12. What Bereaved Families Need • Knowledge • Your time • Comfort & reassurance • Space and time to grieve • Someone to share their journey • Ways to express their grief • Help to build their resilience • To be allowed to have a break from the pain

13. How children make sense of what has happened will depend on a number of factors, including their stage of development

14. Up to 6 months Concepts: Withdrawal of care and nourishment from a familiar person Emotional withdrawal of carer Likely feelings and behaviours: abandonment insecurity anger cries in protest disrupted sleep and feeding routine

15. 6 months – 2 years Concepts: Developing ‘object constancy awareness’ Begins to have mental image of person when absent and can ‘miss’ them Likely feelings and behaviour: Protest and distress Withdrawal Separation anxiety No interest in food or toys Searching behaviour

16. 2 – 5 years Concepts: Establishing that he/she is a separate person Interested in the idea of death in birds, animals etc Understands that death is a part of natural order but lacks ability to appreciate its finality and irreversibility ‘Heaven’ is a physical place: concrete thinking • Likely feelings and behaviour: • Expectations of return - sadness and disappointment • Constant questions • Anxiety about physical needs • Fear of the dark when going to sleep • Toilet regression • Clinging/marked increase in separation anxiety, even when left for short periods

17. 5 – 8 years Concepts: Age of magical thinking Believe they can influence events with thought and behaviour Developing ‘conscience’ so can feel guilt about what their supposed power brings about May think independent events at time of death ‘caused’ it Fuller understanding of concept of death • Likely feelings and behaviour: • Can fear death of others • Especially ‘good’ to compensate for sense of badness, which they believe contributed to the death • Behave badly and therefore draw the punishment they ‘deserve’ • Compulsively caring towards surviving adults or siblings (especially girls) • Cover up sadness by behaving as if nothing happened • ‘Is big now’ and fears behaving in an infantile way

18. 8 – 12 years Concepts: Begins to have an adult concept of death as permanent separation Develops fear /understanding of own mortality, especially in case of sibling death Can imagine how the death will alter his/her future Likely feelings and behaviour: Will display many symptoms of adult grief, but expressed in childish ways May develop anxiety about their own health for fear they may die too Preoccupied at school and social withdrawal

19. 12 + years Concepts: Puberty – time of great change Feelings of ambivalence – separation/dependency Moving from familial ties to increased involvement with peers Becoming aware of issues of life, death and meaning of life Likely feelings and behaviour: Similar to those of adults but have strong inhibitions about expressing them, partly to be ‘grown up’ and partly to avoid being different in their peer group May lead to apathy, withdrawal, depression May express anger in anti-social ways e.g. stealing May take grief outside family

20. Supporting bereaved children

21. How do I talk to a child about death? Aim: to give enough accurate information in an understandable manner, so that the child can answer ‘how’ and ‘why’ in a way that makes sense

22. How do I talk to a child about death? • Be honest • As soon as possible: or may undermine confidence in adults • Begin talking to the child about what he/she experienced or noticed - beginning with the child’s experience makes it harder for the child to deny his own fears and feelings and gives permission for him to trust his own observations • Use the adult reality, facts and words as simply as possible: use the word ‘dead’, not ‘asleep’ or ‘lost’

23. How do I talk to a child about death? • Give child permission to figure out what has happened by letting him/her ask questions as often as wants • Answer questions accurately – say “I don’t know” if you don’t and encourage the child to share his feelings by asking what he/she thinks • Watch out for the child’s tendency to blame him/herself • Give clear message it was not his/her fault • Encourage child to remember and talk about the person who has died, to strengthen positive memories

24. My wife was treated as having lost someone she loved. I was treated as having lost someone I was responsible for A Bereaved Father

25. Culture • We all come from a family culture • In times of stress, people revert to their culturally acquired coping mechanisms • We must never assume a person’s cultural background will dictate their needs and the practices to be followed in bereavement • We need to ask people what is important to them

26. A Dual Process Model of Coping with Bereavement Stroebe & Schut (1999) Everyday Life Experience Restoration-oriented Attending to life changes Doing new things Distraction from grief Denial/avoidance of grief New roles/identity/ relationship Loss-oriented Grief work Intrusion of grief Breaking bonds/ties Denial/avoidance of restoration changes

27. Tasks of Mourning To accept the reality of the loss To experience the pain of grief To adjust to an environment in which the person who has died is missing To emotionally relocate the person and move on with life J William Worden

28. We offer ourselves There are no answers and no explanations adequate to justify the injustice of a baby or child dying …… …but involvement, the sharing of one’s humanity, will make a difference

29. In working with grieving families we all bring our own: • hurts and losses • feelings about loss by death • desire to care for others • ability to reach out and involve ourselves • inability, when overpowered by the tragedy of a child grieving and our own sadness

30. What makes it especially difficult for us: • Concerns children • Normalises what is abnormal • Situation has parallels in your own life • Situation occurs when you are exhausted, in personal crisis • Work climate not supportive

31. AUTONOMIC NERVOUS SYSTEM IS OUR EMOTIONAL SYSTEM WHICH RESPONDS TO EXTERNAL DEMANDS. SEEKS TO KEEP US IN A STATE OF HOMEOSTASIS THROUGH AFFECT REGULATION AROUSAL RESPONSE: SYMPATHETIC WIND DOWN RESPONSE: PARASYMPATHITIC

32. Care providers are helped by: • the mutual support of colleagues • education and training • debriefing soon after events • supervision and mentoring which acknowledge emotions Standards for Bereavement Care Paediatric Intensive Care Society

33. Care providers are helped by: • an open and caring attitude from senior staff • an atmosphere where staff feel able to express their feelings • the opportunity to access psychological help if required Standards for Bereavement Care Paediatric Intensive Care Society

34. We must take the initiative to care for ourselves so that we can feel good about ourselves and our work

35. Supporting Yourself Be aware of your own limitations Access support and supervision to meet your needs Look after yourself physically, emotionally and spiritually Notice any changes in sleep, eating and mood patterns and take action Cherish yourself – you are special Energise yourself by taking regular exercise Dent & Stewart (2004)

36. Survival Factors • Understanding our own emotions • Somewhere safe to express feelings • Access to regular support and supervision • Clarity about boundaries of our role • Ways to relax mind and body • Being part of a supportive team • Life outside work!

37. Look After Yourself • Accept your need for support, both practical and emotional • Be aware of what support is available to you • Establish who is going to provide this • Take responsibility for asking for what you need

38. Website www.childbereavement.org.uk Families Discussion Forum Professionals Discussion Forum Support and Information Line 01494 568900 Email: enquiries@childbereavement.org.uk

41. Award-winning publications and resources