Counseling Children Experiencing Grief

Description of Grief

Many children experience the loss or death of a parent, sibling, grandparent, and even a pet during their formative childhood years. Grief is a normal emotional reaction to loss and death. Although many individuals process grief effectively, some struggle to cope (Cohen & Mannarino, 2011) adequately. Grief symptoms in children vary. Some children exhibit emotional shock and confusion, while some younger children may present with explosive, avoidant, and immature regressive behaviors (Ener & Ray, 2018).

These grief symptoms are exhibited, especially in children who lack an understanding of death and loss. For example, younger children’s understanding of the irreversibility, finality, causality, and inevitability of death can affect their ability to recognize, understand, and process their grief and loss (Ener & Ray, 2018; Willis, 2002). 

Childhood grief symptomology presents somewhat differently than adults although the process is thought to be similar including the following stages: (a) denial (e.g., avoidance or unwillingness to discuss loss); (b) anger (e.g., blaming others for the loss); (c) bargaining (e.g., making promises or changes in one’s situation or life as a means of regaining control); (d) sorrow (e.g., loss of appetite, energy, and motivation); and (e) acceptance (e.g., realization that loss is real and final; Kubler-Ross, 2014; National Association of School Psychologists, 2010). While these stages can be helpful for professional counselors to understanding the universal process of grief, many researchers contend childhood grief should be conceptualized as individual and unique to each child (Cohen, Mannarino, & Deblinger, 2017; Ener & Ray, 2018). 

Professional counselors need to recognize that grief is a process; therefore, symptoms can vary in duration and intensity. When children display grief symptomology for more extended periods, clinical attention is warranted. Individual, group, and family counseling services may be helpful (Cohen et al., 2017; Kress, Paylo, & Stargell, 2019). More specifically, children who experience prolonged periods of depression (e.g., loss of interest in daily activities and/or events), withdraw from friends, are unable to sleep, have prolonged fears of being alone, have drastic drops in school performance, behave much younger than they are, imitate the dead person, andrepeat statements of wanting to join the dead person warrant clinical attention (AACAP, 2018).

Resource:

Kids Health and Grief: https://kidshealth.org/en/teens/someone-died.html

AACAP Grief and Children – Facts for Families: https://www.aacap.org/AACAP/Families_and_Youth/ Facts_for_Families/FFF-Guide/Children-And-Grief-008.aspx?WebsiteKey=a2785385-0ccf-4047- b76a-64b4094ae07f 

Identification/Assessment Strategies

Several factors can contribute to the presentation of grief in children including age of the child, relationship with the deceased, cognitive development of the child, the nature or circumstance around the death of the individual, and the familial and cultural context. Some researchers found that a strong correlation exists between age and behavioral manifestations (Ener & Ray, 2018). In addition to behavioral manifestation, many children internalize their struggles and are at an increased risk of depression, traumatic responses, and functional impairment (Cohen et al., 2017; Edgar-Baily & Kress, 2010; Melhem, Porta, Payne, & Brent, 2013; Webb, 2011a, 2011b). One such assessment measure that has been validated with children who struggle with prolonged grief is Inventory for Complicated Greif-Revised for Children (ICG-RC; Melhem et al., 2013). The use of this measure is recommended. Also, a comprehensive assessment of children who experience grief could include measures of depression, anxiety, and posttraumatic stress while also including assessments that measure behaviors from multiple perspectives (e.g., individual, family, school; Cohen et al., 2017; Pearlman, Schwalbe, & Cloitre, 2010).

Intervention/Treatment Strategies

Cognitive-behavioral therapy (CBT) is an evidence-based approach for addressing grief and loss in children (Cohen & Mannarino, 2011; Cohen, Mannarino, & Deblinger, 2012; Cohen et al., 2017). When counseling children who are experiencing grief, it is essential that their individual needs and level of severity be taken into consideration. What follows are some CBT-based counseling considerations that professional counselors might utilize when counseling children who experienced prolonged grief reactions to loss (Cohen et al., 2017).

Grief Psychoeducation

Professional counselors should use psychoeducation to aid younger children in combating common misconceptions about death (e.g., the deceased individual will return or come back) and assist children in identifying grief and loss reminders and triggers (Cohen & Mannarino, 2011; Cohen et al., 2017; Kress et al., 2019). During this process, professional counselors can help children learn about the typical stages of grief and normalize their associated feelings (e.g., sadness, irritability, despair). In some cases, younger children may need to be taught the definition of death, the difference between being alive and being dead (e.g., breathing, heart beating, brain activity), and the associated concepts/ideas such as finality, causality, and irreversibility. Professional counselors should be mindful of validating children’s feelings, clarify issues of causation (e.g., you did not cause this death; it was not your fault), and allow children to ask all of their questions about death. Since children learn incrementally, children may continue to ask the professional counselor the same or similar types of questions repeatedly. Professional counselors should be patient with children when using the psychoeducation process and allow sufficient time before moving on to other aspects of treatment (Cohen & Mannarino, 2011; Cohen et al., 2017).

Resource:

Grief Education: https://www.therapistaid.com/therapy-guide/grief-psychoeducation-guide The National Child Traumatic Stress Network:

https://www.nctsn.org/what-is-child-trauma/trauma-types/traumatic-grief  The National Child Traumatic Stress Network- Guide for Parents:

https://rems.ed.gov/docs/SAMHSA_ChildhoodTraumaticGriefForParents.pdf 

Creating a Grief and Loss Narrative

An essential grief counseling component is allowing children to tell their stories in their own words (i.e., creating a grief and loss narrative). Professional counselors can use these grief and loss narratives to gradually expose children to their lived experiences while slowly incorporating newly revealed aspects of their loss either verbally or as a written narrative (Cohen et al., 2017; Cohen & Mannarino, 2011). This exposure aspect is vital and helps children to tolerate and integrate aspects of their individual experience, an essential aspect of the grieving process. Professional counselors using this narrative approach help children increase their level of awareness, level of communication, and reduce their tendencies to repress or not process their grief and loss (Cohen et al., 2017).

Encourage Processing of the Loss

In some situations, professional counselors may need to encourage children who are reluctant to share and process. Creating a warm and non-judgmental space and place can help children to feel comfortable to grieve their loss and to discuss aspects and memories of what they miss about the deceased persons.

Professional counselors may want to help children process grief by having the child recall memories they shared with the person, what they learned from that person, what they are going to miss about the person, and how their world was better because of that person (Cohen et al., 2017). Using a name anagram is one activity that can be used to assist children who are beginning to explore their losses.

Professional counselors can help the child assign a special memory, phrase, or a positive thought with each letter of the deceased person’s name. This activity can begin to encourage children to identify and process their grief.

Resources:

Clinical Grief Activities: http://schoolcounselorsconnect.weebly.com/uploads/1/0/2/4/10242617/clinical_ grief_activities_booklet.pdf

10 book on death for younger readers: https://www.funeralguide.com/blog/10-childrens-books-on-death- grief-and-loss

Addressing Ambivalence

Varying levels of ambivalence are to be expected. Some children present as overly ambivalent about their losses. Other ambivalence often includes memories associated with the deceased person that the child will not necessarily miss (Cohen & Mannarino, 2011). Children may have an increased level of ambivalence due to past abuse from the deceased person, shame around the cause of death (e.g., overdose, suicide), unresolved anger or resentment, or feelings the death was not necessary (e.g., not getting needed medical attention; Cohen et al., 2017). In older children, a professional counselor can ask the child to write a letter to the deceased person to help address any unresolved thoughts, feelings, and struggles (Edgar-Baily & Kress, 2010). In situations where the child is too young to write a letter, a professional counselor can either write down the child’s thoughts or have the child create drawings that will help depict the child’s feelings related to their struggle. These therapeutic letters are not intended to be shared with anyone. However, clinically relevant themes such as “you didn’t love me” or “you did not think about how this would make me feel” may emerge. During this process, professional counselors can help children explore any regrets that may exist or present. One activity that counselors can use to extract this information is to formulate incomplete sentences (e.g., I am sorry that …; It is my fault …; I blame myself …; I wish I could …). Asking these types of questions can assist children to address their ambivalence toward grief and loss Cohen & Mannarino, 2011; Kress et al., 2019).

Focusing on Positive Memories

Professional counselors should be mindful to help children identify, recall, and discuss positive memories of the deceased person (Cohen et al., 2017). Recalling positive memories helps children to progress through bereavement and to commemorate the deceased person (Edgar-Baily & Kress, 2010). Specifically, counselors help children to discuss how their world will be different without their loved ones and how they will begin to celebrate or commemorate the deceased person. Increasing the in-session reminiscing of positive memories and experiences can help build children’s abilities to tolerate discussions involving the deceased person. The creation of a memory book or box is an example of one activity that can assist children in recalling and preserving positive memories of the decedent. Children can construct a memory book or box by collecting, cutting out, and gluing mementos, pictures, drawings, and letters about the deceased loved one into a photo album and/or onto a box. Professional counselors can instruct older children to write down these positive memories, compose a letter, create a collage, or produce a record or video to put with the book or in the box. In addition, the counselor may elect to assign the child homework to schedule a specific day and time to recall and review these memories throughout the week (Cohen et al., 2017).

Meaning Making

One of the most important aspects of grief counseling is assisting children and families in making meaning of the grief they experience (Cohen et al., 2017). As children learn to express their grief and loss more openly and feel that others understand their experience, they can begin to create a sense of meaning to their experience. Professional counselors can facilitate children making meaning of their experience by helping them process what aspects of the relationship they choose to remember (e.g., memories, life lessons, love) and how their relationship with the deceased has prepared them to move forward into the future. One activity counselors can suggest that may aid children and families in meaning-making is to facilitate a memorial service. Specifically, professional counselors can help children prepare, formulate, and share memories, experiences, and lessons they learned from the deceased loved one, ultimately, aiding them in making meaning of their grief and loss.

Integration and Moving Forward

An essential aspect of grief counseling is the integration of memories and experience into the child’s new reality (Cohen et al., 2017). One way for children to conceptualize this phase of treatment is helping them understand that although the deceased person is gone, their memories live on in their lives. During this phase of treatment, counselors can begin to use the past tense when referring to the deceased loved one.

Professional counselors can help children distinguish between what aspects of the deceased lives on and what aspects have been lost by their deaths. Incorporating the use of balloons is one activity that can aid children to distinguish and identify what parts of the relationship they are able to hold onto and what parts of the relationship they need to relinquish (e.g., let go; Cohen et al., 2012). Professional counselors can instruct children to draw a picture of themselves holding a balloon and another one floating away.

In the first balloon (the one they are holding), the children should list or draw all of the things they will be holding onto from the deceased (e.g., love, experiences/memories, lessons). In the other balloon (the one floating away), the children can draw or write all the things that represent what they think needs to be let go (e.g., future memories, being able to be with them). Professional counselors can choose to use real balloons and follow a similar process as a means for children to symbolically let go of the aspects of the relationship that need to relinquish.

Addressing Expectations for the Future

Part of processing grief requires children to address their loss in the context of their expectations for the future. While the exploration of these expectations solely depends on the age and developmental level of the child, these discussions tend to be more appropriate for adolescents. Allowing children to express their expectations about future activities they will experience without the deceased loved one can be beneficial for a child to process grief. In addition, counselors should help children explore how children’s roles with others may now need to change (secondary to this loss) and how others may aid them in navigating this change. Helping children explore options for how to have their needs met within the context of their current relationships can also help create new expectations for the future (Kress et al., 2019).

Planning for the Future

Finally, professional counselors need to help children and families plan for the future (Kress et al., 2019). As counseling concludes, professional counselors should assist children in planning and preparing in order to manage future reminders and triggers. These reminders and triggers are often associated with special dates (e.g., birthday, date the deceased passed, holidays), specific events (Mother’s/Father’s Day, anniversary), and changes that affected the child or family (e.g., change of living situation, change of school, change of home). Helping children identify and plan for these reminders and triggers in advance can aid them in grieving and aid them in being intentional about commemorating and celebrating the deceased loved ones on the children’s own terms.

Resources:

National Alliance for Grieving Children: https://childrengrieve.org/

The National Center for Grieving Children and Families: https://www.dougy.org/grief-resources/how-to- help-a-grieving-child/