Bereavement Support: Supporting Children, Adolescents, and the Care Team
Introduction
Whether we are mourning the loss of a loved one, a diagnosis with a serious illness, loss of employment, or uprooting of our community, we are all grieving in our own, individual ways.
Grief is a large, nebulous concept and emotional experience that can be challenging to singularly define. Despite these idiosyncrasies, there are common feelings in grief that are salient: deep sadness, yearning, anger, anxiety, relief, resentment, and disbelief to name a few. Grievers are often an underrepresented and underserved population depending on cultural norms and practices around death and dying.
Grief is a lifelong process that ebbs and flows, morphing over time without a prescribed ‘end point.’ Eventually, we learn to live alongside our grief.
We humbly acknowledge the complex and multifactorial losses in Ukraine, the ripple effects of which will continue to be felt for generations. The hope of this page is to provide concrete resources and foundational principles of grief and bereavement that can be readily used in clinical practice.
We also hope for this information to bring even a sliver of comfort as Ukrainians continue to navigate this ever-changing time.
We also hope for this information to bring even a sliver of comfort as Ukrainians continue to navigate this ever-changing time.
Definition of Terms
Grief – Internal experience of emotions after a loss (death of loved one, divorce, job loss, etc.)
Bereavement – Period of time following a loss in which you experience grief and express mourning
Mourning – Outward expression of grief (funeral traditions, wearing black, sitting Shiva, etc.)
Five Stages of Grief – The ‘five stages of grief’ is a model developed by prolific psychiatrist and researcher Elisabeth Kubler Ross in 1969, which was published in her book “On Death and Dying.” Ross ascribed this model to the dying process after interviewing thousands of patients at the end of their lives.
She found the five stages – denial, anger, bargaining, depression, acceptance – as universal themes experienced by dying people. Over time, these stages were transcribed to the grieving process.
It is important to note that this is only one model for describing grief. Grief is not a linear process and does not occur in neatly defined, sequential stages. Families often experience many emotions at one time or swing between different feelings depending on the moment. (“Five Stages of Grief,“ What’s Your Grief, 2022)
She found the five stages – denial, anger, bargaining, depression, acceptance – as universal themes experienced by dying people. Over time, these stages were transcribed to the grieving process.
It is important to note that this is only one model for describing grief. Grief is not a linear process and does not occur in neatly defined, sequential stages. Families often experience many emotions at one time or swing between different feelings depending on the moment. (“Five Stages of Grief,“ What’s Your Grief, 2022)
Secondary Loss – Peripheral losses that occur as a “side-effect” of grief. These losses occur secondary to the primary loss of a loved one and are often unrecognized. Secondary losses can include, but are not limited to, losses of: income/financial stability, faith or belief system, support or social network, hopes for the future or dreams, role or identity, and confidence or esteem.
For example, a woman who just lost her husband may experience loss of second income, supportive network, and loss of dreams for the future. (“Dive into Secondary Loss,” What’s Your Grief, 2021)
For example, a woman who just lost her husband may experience loss of second income, supportive network, and loss of dreams for the future. (“Dive into Secondary Loss,” What’s Your Grief, 2021)
Disenfranchised Grief – Losses that are not openly discussed, acknowledged, or recognized by your community or greater society.
These are typically non-death losses, such as sense of identity, support, community, or role. Secondary losses are often described as disenfranchised as these losses often go unrecognized, leaving grievers feeling invalidated and unsupported. It can be tremendously empowering for clinicians to name and acknowledge these losses.
These are typically non-death losses, such as sense of identity, support, community, or role. Secondary losses are often described as disenfranchised as these losses often go unrecognized, leaving grievers feeling invalidated and unsupported. It can be tremendously empowering for clinicians to name and acknowledge these losses.
Ambiguous Loss – Loss that is experienced as uncertain or unresolved that leaves the griever feeling especially conflicted and/or confused. These types of loss typically occur when:
- someone is physically present but psychologically absent (i.e. Alzheimer’s, dementia, etc.),
- someone is physically absent but still possibly alive (i.e. prisoner of war, kidnapping, absentee parent),
- someone is physically present but the relationship has been altered (i.e. divorce, break ups, etc.).
Developmental Understanding of Grief in Children and Adolescents
(“Developmental Responses,” 2017)
Infants-Babies (0-1)
Understanding:
- No cognitive understanding
- Sense changes in routine
- Feel disrupted by changes in consistent caregivers
- Perceive the absence of the deceased as separation or abandonment
Expected Behaviors:
- Regression in developmental milestones
- Changes in sleep and eating patterns
- Fussiness or harder to soothe
- Inconsistent or atypical attachment
Ways to Support:
- Keep routine and schedule consistent when possible
- Provide nurturance and physical security, such as holding and cuddling
Toddlers (2-5)
Understanding:
- Do not understand finality and irreversibility
- Magical thinking- belief that one’s ideas, thoughts, actions or words can influence the court of events in the material world
- Egocentric- thinking of oneself
- Express themselves through play and behaviors
Expected Behaviors:
- Clinginess
- Temper tantrums or behavioral outbursts
- Regression in completed milestones (e.g., potty training, sleeping through the night)
- Repetitive questions or perseverating on the topic through play and conversations
Ways to Support:
- Keep routine and schedule consistent when possible
- Provide short and concrete explanations about how death occurred
- Provide opportunities to express emotions through play
- Help children identify their feelings and fears
Children Ages 6-9
Understanding:
- Concrete thinking- focused on physical world, not abstract
- Magical thinking – belief that one’s ideas, thoughts, actions or words can influence the court of events in the material world
- Do not fully understand irreversibility and finality of death
- May perceive death as punishment or feel responsible
Expected Behaviors:
- Disrupted sleep patterns and nightmares
- Regressive behaviors (e.g. bed wetting, thumb sucking)
- Concerns about safety and abandonment
- Mood swings and behavioral outbursts
- Anxiety and sadness manifested as physical symptoms (e.g. stomach ache or headache)
Ways to Support:
- Concrete and honest language
- Consistent routine and schedule when possible
- Opportunities for play, especially physical releases of energy
- Normalize and label feelings
- Create safe space to express themselves and ask questions
- Provide reassurance that they are not responsible
- Model positive coping
- Share positive memories of the deceased
Children Ages 10-12
Understanding:
- Understand finality and inevitability
- Starting to understand abstract thinking, ability to think about objects, principles, and ideas that are not physically present.
- Focus on more specific details about the death
- May feel regret and guilt
Expected Behaviors:
- Acting out or behavioral outbursts
- Hypervigilance
- Nightmares
- Increase in sensitivity
- Anxiety and sadness may manifest as physical symptoms (headache/stomachache)
- Detailed questions
- Withdrawal from social situations
- Testing the limits
Ways to Support:
- Answer questions honestly
- Provide opportunities for expression
- Help identify activities and people that make them feel safe and supported
- Model expression and labeling of emotions
- Model positive coping techniques
- Share positive memories of the deceased
- Encourage ideas to honor the deceased
Teenagers (Ages 13+)
Understanding:
- Understand irreversibility, finality, inevitability, and causality
- Recognize death as universal (and they, too, will eventually die)
- Question their own self-identity and religion/culture
Expected Behaviors:
- Withdrawal from family and other supportive individuals
- Increased focus on support through peers
- Risk taking behavior
- Utilize social media to express themselves and connect with others
- Inability to focus or hyper-focused on succeeding
- Anxiety and depression may manifest as physical symptoms (e.g. stomach ache)
- Take on parent/caregiver role
- May have thoughts of self-harm or thoughts of suicide
- Lack of joy in previously preferred activities
- Intense mood swings
Ways to Support:
- Reinforce safety and security
- Allow for expression of feelings without judgment or trying to fix it
- Maintain routines
- Set clear expectations and rules
- Connect with outside trusted adult if prefer not to talk to parents/caregivers
- Watch for signs of anxiety and depression
- Identify concerns for suicidal ideation or self-harm and seek support for safety
Strategies
Mindfulness-Based Skills: Mindfulness is defined as the ‘quality or state of being conscious or aware of something.’ There are three key qualities to developing a mindfulness practice:
- Development of awareness,
- Attention and observation of the present moment,
- A non-judgmental and curious attitude or mindset.
Mindfulness strategies can be particularly grounding during times of uncertainty and grief, as we strengthen the muscles in our brain to practice being mindful.
Mindful practices are often helpful to center the mind during grief waves and to cultivate an awareness between the brain-body connection. Mindfulness strategies have long been used by clinicians to support people in navigating their grief.
Exercises:
1. Loving Kindness Meditation: This short meditation, or “metta,” invites participants to practice gratitude to thyself and to others.
Meditation has been proven to increase resilience, decrease negative self-talk, and improve positive emotions (Madhuleena Roy Chowdhury, 2022).
To practice the Loving Kindness Meditation, begin by finding a comfortable position for your physical body (sitting, lying, etc.). Identify your statements you wish to meditate with. Here are some common examples:
May I be peaceful
May I be happy
May I be safe
May I be happy
May I be safe
Take your time in repeating these words. When you feel ready, you may choose to extend these thoughts to others. Here are some common examples:
May you be peaceful
May you find happiness
May you be safe
May you find happiness
May you be safe
This meditation can be done in just a few minutes, offering a moment to recenter and ground. The Berkeley Greater Good in Action Program offers a guided listening Loving Kindness Meditation here: https://ggia.berkeley.edu/practice/loving_kindness_meditation
2. Practice of Self-Compassion: “Self-compassion is a practice of goodwill, not good feelings” (“Self Compassion,” 2021) and is described by positive psychology researcher Kristin Neff as offering self-kindness (instead of judgment), identifying with common humanity of others (as opposed to isolation from feelings), and continued practice of mindfulness (Neff, 2003).
The essence of self-compassion is honoring your feelings, even when they are hard–even in grief.
We can practice self-compassion by acknowledging and naming feelings of grief (i.e., “I am feeling anxious in my grief today) without judgment. Imagine caring for yourselves in these moments as you would a friend, allowing gentleness and kindness towards the self.
3. Five Finger Breathing Exercise: This mindfulness exercise is helpful for people of all ages, but is an especially useful strategy for children.
As children are experiencing fluctuations in their grief, this technique can be used as both a grounding exercise and education in social-emotional learning. (“Five Finger Breathing,” 2022).
Directions:
- Step One: Spread one hand apart either in front of you or on the ground.
- Step Two: Use the index finger of the opposite hand to trace up the outside of your thumb. Take a deep breath as you trace up to the tip of your thumb.
- Step Three: Exhale as you trace your index finger down the inside of your thumb.
- Step Four: Repeat this on the remainder of your fingers: Inhaling as you trace up one side, exhaling on the way down.
Support for Clinicians: Grief experienced by clinicians is found on varying levels: personal losses, bearing witness to patient/family grief, or holding the weight of community/global grief. In order to continue caring for our own families, our patients, or our communities, we also must be thoughtful in the approach to sustainability. Each individual clinician will find what is most therapeutic in supporting their continued work in medicine.
We also recognize that many clinicians do not have the time resources to engage in self-care strategies that are most meaningful in their practice. We often recommend utilizing debriefing, both formal and informal, to support clinician coping.
Debriefing in the moment may occur as a short conversation between colleagues, in a group setting with other professionals over a meal, or while with family and friends. In these moments, a technique called low-impact debriefing, a trauma-informed technique for sharing and processing the difficult stories and images that we see and hear about through our work as helping professionals (Mathieu, 2013) can be utilized by clinicians.
Low-impact debriefing involves looking at how to avoid “sliming,” defined as receiving or witnessing unnecessary traumatic content without warning or permission, with colleagues by following rules around self-awareness, giving fair warning, and getting consent to share (Chadwick Trauma-Informed Systems Dissemination and Implementation Project, 2016).
This concept is described in more detail in Low Impact Debriefing: Preventing Retraumatization: https://www.tendacademy.ca/lid/.
Formal debriefing techniques can occur on a regular or ad hoc basis and varies on work setting, clinician capacity to dedicate time, and individuals involved. The pediatric palliative care program of the Johns Hopkins Children’s Center developed a bereavement debriefing session for healthcare professionals.
This intervention is specifically aimed at providing emotional support and increasing one’s ability to manage grief and was developed as part of a quality improvement project to improve care of children with life-threatening conditions (Keene., et al 2010).
Bereavement debriefing sessions can be one aspect of an effective approach to supporting health care professionals in managing their grief.
Rituals for Clinicians: Engaging in a ritual to acknowledge death and grief in a meaningful way while being aware of time can be helpful for clinicians.
The Pediatric Advanced Care Team and Boston Children’s Hospital and the Dana Farber Cancer Institute utilizes a “Pause” to support emotional healing and resiliency. It is not meant to replace a medical review of a case or situation that can occur at a later time.
The Pause: “Let us take a moment to acknowledge our experiences in caring for the [patient’s last name] family. [Patient’s name] is loved enormously in this world by [Parents’ Names or “their family”]. In our own way and in silence let us take a moment to honor [patient’s name].”
For Example, patient “Bob Smith”
“Let us take a moment to acknowledge our experiences in caring for the Smith family. Bob is loved enormously in this world by his family (can also say specific names). In our own way and in silence let us take a moment to honor Bob.”
Summary
Grief can bring a complex set of emotions and is a lifelong experience. While these tools and strategies will never “fix” grief, we hope they can offer some comfort in navigating the range of complex feelings that arise throughout a crisis.
As clinicians caring for patients experiencing grief, there can often be elements of countertransference, defined as the set of cognitions, affects, and behaviors that the clinician experiences towards the patient that impact our reactions and responses (Hofsess and Tracey, 2010).
It is critical that we, as clinicians, prioritize caring for ourselves as part of patient care, to continue serving and caring for our patients, families, and communities.
Resources
US-Based Online Resources:
- The Dougy Center: Offers practical information about supporting grieving children and articles for bereaved caregivers.
- Judi’s House: Provides resources for grieving children as well as clinicians, teachers, and other adults who may support children in their scope of practice. Judi’s House conducts annual research on the impact of pediatric grief as a public health crisis.
*Some of the above resources contain training opportunities that we cannot corroborate. We are not affiliated with any of the listed resources, references, or websites.*
International Resources
- Red Cross: Virtual Family Assistance Center: Provides emotional support and access to resources such as the national Disaster Distress Hotline that is available 24/7 providing immediate crisis counseling for people experiencing emotional distress related to any disaster or COVID-19.
- IFRC Psychosocial Guide: There are various resources on this page about how to talk with children about global events. This particular guide offers support for talking with children about war.
References
- A deep dive into secondary loss. Whats your Grief. (2021, April 29). Retrieved February 1, 2023, from https://whatsyourgrief.com/a-deep-dive-into-secondary-loss/
- Chadwick Trauma-Informed Systems Dissemination and Implementation Project. (2016). Secondary traumatic stress in child welfare practice: Trauma-informed guidelines for organizations. San Diego, CA: Chadwick Center for Children and Families.
- Developmental responses to grief. The Dougy Center . (n.d.). Retrieved February 6, 2023, from https://www.dougy.org/assets/uploads/Developmental_Responses_2017.pdf
- Five things about the ‘five stages of grief’ – what’s your grief. What’s your Grief. (2022, June 8). Retrieved February 1, 2023, from https://whatsyourgrief.com/five-stages-of-grief/
- Hofsess CD, Tracey JG. Countertransference a prototype: the development of a measure. J Couns Psychol. 2010; 57: 52-67. https://doi.org/10.1037/a0018111.
- Keene, E. A., Hutton, N., Hall, B., & Rushton, C. (2010). Bereavement debriefing sessions: an intervention to support health care professionals in managing their grief after the death of a patient. Pediatric nursing, 36(4), 185–190.
- Madhuleena Roy Chowdhury, B. A. (2022, September 12). What is loving-kindness meditation? Retrieved February 1, 2023, from https://positivepsychology.com/loving-kindness-meditation/
- Mathieu, F. (2013, May 31). Low impact debriefing: Preventing retraumatization. Retrieved from http://www.tendacademy.ca/low-impact-debriefing-how-to-stop-sliming-each-other/
- McClaney, V. S. (2022, July 1). Practice five-finger breathing and mindfulness . PBS SoCal. Retrieved February 1, 2023, from https://www.pbssocal.org/education/practice-five-Finger-breathing-mindfulness-easy-turkey-craft
- Neff, K. D. (2003). The development and validation of a scale to measure self-compassion. Self and Identity, 2(3), 223–250.
- Tips for practice – self-compassion. Self. (2021, August 8). Retrieved February 1, 2023, from https://self-compassion.org/tips-for-practice/