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Children, Adolescents, Grief, and Trauma Kenneth J. Doka, PhD Professor, The College of New Rochelle Senior Consultant, The Hospice Foundation of America – PowerPoint PPT presentation

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Title: Children,%20Adolescents,%20Grief,%20and%20Trauma


1
Children, Adolescents, Grief, and Trauma
  • Kenneth J. Doka, PhD Professor, The College of
    New Rochelle
  • Senior Consultant, The Hospice Foundation of
    America

2
Four Goals
  • To review how concepts of death change throughout
    the life cycle
  • To explore the ways that children and adolescents
    experience loss
  • To discuss strategies to assist children and
    adolescents
  • To examine the particular issues raised by
    traumatic loss

3
Developmental Perspectives on Death
4
The Kingdom Where Nobody Dies
  • The myth of children and loss

5
Children Historically Dealt with Death and Loss
  • Fairy Tales
  • Games
  • Books and Stories
  • Jokes
  • Songs

6
Children Are Constantly Exposed to Loss and Death
  • Television
  • Music
  • News
  • Experience

7
Yet, Children Are Constantly Developing
  • Cognitively
  • Emotionally
  • Socially
  • Spiritually

8
Young Children
  • Animistic
  • Artificialistic
  • Blur boundaries between life and death
  • Yet, all gone an early concept

9
Children Develop in Their Cognitive Mastery of
Death
  • Conceptualizing Death
  • Universality
  • Nonfunctionality
  • Irreversibility
  • Causality
  • Continuation

10
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11
Young Children Have a Short Feeling Span
  • They can sustain intense emotions for a short
    time (Crenshaw)
  • Implications for counseling

12
Children Develop Socially
  • Cooleys Play and Game Stage
  • The Development of Empathy

13
Children as Spiritual Pioneers
  • R. Coles, The Spiritual Lives of Children

14
Discussing Death with Children
  • Always make sure you know the question the child
    is asking and the context (Why is the question
    being asked now?)
  • Be honest but reassuring
  • Keep the dialog open
  • Ask for feedback
  • Share faith and feelings

15
Development Continues Through Adolescence
  • Young
  • Middle
  • Old

16
Death is a Significant Undercurrent Adolescence
  • The Three Is Independence, Identity,
    Intimacy
  • Time of critical evaluation
  • Significant separations
  • Problematic experiences of death
  • Defended against by present orientation

17
Loss and Grief in Children and Adolescence
18
Children Are Embedded in Webs of Relationships
  • Family
  • Friends
  • Neighbors
  • Teachers
  • Coaches
  • School
  • Faith Communities

19
Children Experience Many Losses
  • Death
  • Divorce
  • Separation
  • Loss of Dreams
  • Relocation

20
Some Losses May Be Catastrophic
  • Abandonment
  • Foster Care Placement
  • Fire, Disaster
  • Homelessness, Eviction, Rapid Relocation

21
At What Age Can Children Mourn?
  • With object constancy (around 3 years-old)
  • Only with adolescent development of identity

22
Wordens Answer
  • Children mourn at any age but different from
    adults

23
My Comment
  • Children mourn at any age but different from
    and similar to adults

24
Grief May Be Manifested in Many Ways Similar to
Adults
  • Physically
  • Emotionally
  • Cognitively
  • Spiritually
  • Behaviorally

25
Manifestations of Grief
  • How sees homesick kids first?
  • Children are prone to somatically display their
    grief reactions
  • Misinterpret physical manifestations of affect
  • Care eliciting
  • Assess physical reactions such as aches and pains
    persistent complaints should be treated

26
Manifestations of Grief
  • Emotionally children may have similar reactions
    to adults
  • Sadness
  • Fears and anxieties
  • Guilt and magical thinking
  • Anger and the lack of control
  • Other emotions

27
Manifestations of Grief
  • Grief affects children and adults cognitively
  • Depersonalization and denial
  • Problems with concentration, lack of focus,
    impaired thought
  • Many of the manifestations of grief can mimic
    learning disabilities
  • Importance of loss inventory

28
Manifestations of Grief
  • Children may react behaviorally in many of the
    same ways as adults avoiding or seeking
    reminders, withdrawal, crying
  • And spiritually struggling with doubts, anger,
    or spiritual questions

29
Continuing Bonds
  • Memories
  • Biography
  • Legacies and liabilities
  • Spiritually
  • Extraordinary Experiences (LaGrand)

30
The Grief Process A Roller Coaster of Reactions
31
Stroebe and Schut Dual Process Model
  • Calls for Oscillation between
  • Loss-Oriented Processes
  • Restoration Processes

32
Grief is not a time-bound process that ends in
detachment
33
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34
Amelioration of Grief
  • Over time pain lessens
  • Persons function at similar (or sometimes better
    levels) than prior to the loss
  • Yet, grief still has a developmental aspect

35
Yet, there are also differences
  • To Bowlby early loss may impair trust and create
    attachment issues throughout life (perhaps
    mitigated by continuity, story)
  • Crenshaw and the crisis of impending connection

36
Other Differences
  • Manifestations may include acting out, sleep
    disturbances, regressive behaviors, accidents,
    changes in behavior or grades
  • Children may re-grieve earlier losses

37
Children and Adolescent Grief
  • Thus children and adolescents may experience
    periods of grief throughout the life-cycle
  • In early loss, the re-grief phenomenon
  • As they struggle with identity
  • Developmental surges

38
Grief takes place in a family context
  • The Harvard Bereavement Study isolated a number
    of risk factors for both the child and the
    family. Yet, these are best summarized as the
    best predictor of the childs adjustment is the
    ability of the surviving parent to function.

39
The Issue of Trauma
  • Grief and Loss
  • The Loss of an Assumptive World
  • Mistrust and Anxiety
  • Resonating Trauma (Rumor and the restoration of
    the assumptive world)

40
The Damocles Syndrome
  • Koocher s et al study of children who survived
    childhood cancer felt a heightened sense of
    mortality throughout their lives
  • This heightened sense of mortality was labeled
    the Damocles Syndrome
  • May be present for children who survive or
    witness a traumatic Event

41
Adolescents Often Experience Difficulty as They
Grief
  • Discomfort with differences
  • Ability to seek support from adults
  • Limits to peer support
  • Time of spiritual questioning

42
Adolescent Grief
  • Acting Out (including behaviors, substance abuse,
    sexual, eating disorders)
  • School Performance
  • Changes Yet, Note Development
  • Self-Esteem
  • Anxiety

43
Adolescent Grief The Internet as Support
  • Technology as difference
  • Adolescents as Digital Natives (rather than
    Digital Immigrants)
  • 93 use the Internet, 79 of 15-17 year-olds
    have cell phones
  • Prevalence of MySpace and Facebook

44
Adolescents and the Internet
  • The Internet allows experimentation with
    different personas
  • Internet relationships can offer a sense of
    belonging
  • The Internet can offer the possibility of
    validation without risk
  • The Internet offers information independent of
    asking adults

45
Adolescent Grief The Internet as Support
  • The Internet offers information about grief
  • There are opportunities to memorialize online
  • One can express grief to peers and others in
    blogs
  • One can offer and receive support including in
    online support groups

46
The Internet and Adolescent Grief Support Dangers!
  • Information may not be accurate
  • Support groups may lack professional supervision
    and even be unsupportive
  • Comments by others can be hateful, harmful, or
    denigrating
  • The danger of vulnerable adolescents and online
    predators
  • Internet options may make the adolescent less
    available for more suitable and qualified
    assistance

47
The Internet and Adolescent Grief Support
  • Points for the Counselor
  • Ask adolescents about the Internet and if and how
    they are using it as they cope with their grief
  • Create an ongoing dialogue about their Internet
    use

48
Disenfranchised Grief Sensitivity to Online
Relationships
  • Online Relationships
  • Chat Room Relationships
  • Participants in massively multiplayer online
    role-playing game (MMORPG)
  • The funeral of Toxik/Chris

49
Schools Can Play a Critical Role
  • Academic
  • Social and Developmental Arena
  • Sources of Formal and Informal Support
  • Early Warning System
  • Links Families

50
Assisting the Grieving Student
  • Acknowledge loss
  • Understand grief
  • Offer support (including groups)
  • Empower natural networks
  • Recognize developmental needs
  • Problem solve
  • Sensitivity with Projects/Events

51
Assisting the Class
  • Open communication
  • Prepare (with parents) class for possible changes
  • Empower peer support and deal with class affect
  • Have school nurse explain illness and address any
    questions or anxieties
  • Assist teachers
  • If appropriate inform other parents

52
The Letter Home
  • Privacy and permission with illness check with
    parents
  • Send not with a child (note in some districts
    email can work or a phone alert that a letter
    is coming with the child)
  • Contents
  • What happened
  • How the school responded
  • What your child may experience
  • Available sources of help

53
When a Student Dies (or other school-related
death)
  • Information chain (VERIFY!)
  • Inform students
  • Encourage discussion
  • Provide support and counseling (and identify at
    risk)
  • Allow students to self-select into counseling as
    well
  • Encourage and empower outreach
  • Shape group response
  • Inform parents
  • Remove papers in normal cycle
  • Automatic communications? (PTA notices etc)
  • Support staff

54
How can we help children and adolescents adapt to
loss?
55
General Principles
  • Sensitivity to Loss
  • Validation

56
Communicating with Children
  • What can they understand?
  • What do they want to know?
  • What do they need to know?

57
Empower Families
  • Childrens Grief Takes Place in a Family Context
  • Assess Rules and Communication
  • Risk Factor Parental Functioning
  • Note Extended Family/ Intimate Networks

58
Parents Can Help
  • Assess their functioning and the functioning of
    the child
  • Assess their messages to the child
  • Allow and validate grief
  • Encourage support
  • Encourage ritual

59
Illustration Children and Funerals
  • Importance of Ritual including Spiritual
  • Value of Personalization and Participation
  • Choice
  • Information
  • Options
  • Support

60
Effective Support for Children The Value of
Family Centered Counseling
  • Provide Support for Parents
  • Process their grief
  • Skill-building including teaching them how to
    assist their children with secondary loss
  • Provide Support for Children
  • Grief support
  • Adjusting to a new life

61
Tripartite Assessment (Webb)
  • Individual Factors
  • Loss-Related Factors
  • Socio-Cultural Factors

62
Individual Factors
  • Age/developmental level
  • Past coping
  • Global assessment
  • Medical history
  • Past loss experience

63
Medical History
  • Check on use of psychotropic drugs as this is the
    most medicated generation in history
  • The role of psychotropic drugs such as Ritalin is
    yet unknown but certainly may distort the
    experience of grief
  • Remember that grief and some learning
    disabilities share common manifestations

64
Medical History
  • With adolescents assess (non-judgmentally)
    alcohol and drug use
  • Depending on age and initial assessment, this can
    be done as an assumptive fact How often do
    you drink beer?
  • Drug and alcohol use can be a problematic way to
    cope with loss and even constitute a pattern of
    masked grief

65
Loss-Related Factors
  • Relationship
  • Type and circumstance of loss
  • Grief reactions

66
Socio-Cultural Factors
  • Nuclear and extended family
  • Social support
  • Peer support
  • Culture
  • Religion/Spirituality

67
The Tasks of Grief
  • Acknowledge the loss
  • Express manifest and latent emotion
  • Adjust to a changed life
  • Relocate the loss
  • Reconstitute faith and philosophical systems
    challenged by the loss
  • Worden (Modified)

68
The Work of Children is Play (Webb)
  • The Value of Expressive Approaches
  • Natural
  • Reflective
  • Cathartic
  • Projective
  • Be Prescriptive

69
The Tasks of Grief Acknowledge the Loss
  • Barriers
  • Cognitive understanding
  • Adult protectiveness
  • Unclear language
  • Limited experience
  • Strategies
  • Value of clear language and open communication
  • Supported visits (hospitals etc.)
  • Presence at rituals
  • Drawing or acting out events

70
The Tasks of Grief Express Manifest and Latent
Emotion
  • Barriers
  • Short feeling span of young children and limited
    vocabulary
  • Protecting parents
  • Adolescent defensiveness
  • Strategies
  • Five faces, feeling games and feeling checks
  • Expressive approaches
  • Connecting feelings and actions
  • Assess self-blame and unrealistic thinking

71
The Tasks of Grief Express Manifest and Latent
Emotion
  • Two Critical Issues
  • Ambivalence
  • Understanding ambivalence
  • Secondary gains
  • Powerlessness of children
  • Finishing Business
  • Definition
  • Approaches

72
The Tasks of Grief Adjust to a Changed Life
  • Barriers
  • Lack of control over changes
  • Cognitive understandings (with young children)
  • Strategies
  • Empower communication between parents and
    children
  • Emphasize the value of true choice
  • Anticipate difficult days
  • A magic wand

73
The Magic Wand
  • An effective way to assess children and
    adolescent thinking and fantasies
  • If you had a magic wand, what would you change?
  • How would that make you and your life different?

74
Inner Representation and Relocation
  • When a child dies, Klass reminds that parents and
    children carry an inner representation of the
    child
  • Very aware of how old the child would be now and
    carrying an image of the childs appearance or of
    how the child would be
  • Excessive idealization may negatively affect
    surviving children

75
The Tasks of Grief Relocate the Loss
  • Barriers
  • Short feeling and attention spans of young
    children
  • Protection of parent
  • Family rules
  • Strategies
  • Timelines and life histories
  • Memory books, albums, and boxes (note social
    class implications)

76
Adolescent Memorializing
  • Adolescents may have special ways of
    memorializing
  • Wall Memorials, graffiti
  • RIP Tattoos, Body Art
  • RIP tee shirts or other clothes
  • Memorial Blogs or Site
  • Auto Markings
  • Memorial Jewelry
  • Barrett, 2009

77
The Tasks of Grief Reconstitute Faith and Beliefs
Challenged by Loss
  • Barriers
  • Children as spiritual pioneers
  • Adolescent questioning
  • Strategies
  • Empower parents and other adults to share how
    their beliefs help them in this loss
  • Spiritual stories
  • Explore and validate loss of assumptive world
    (meaning making strategies)

78
Expressive Approaches
  • Art
  • Movement/Drama/
  • Role Play
  • Crafts
  • Storytelling/Poetry/
  • Creative Writing
  • Photography/Videos
  • Music/Dance
  • Games

79
Corrs Guidelines for Bibliotherapy
  • Read and evaluate the book
  • Select appropriate title for capability and
    context
  • Cope with limitations
  • Discuss with child

80
The Value of Therapeutic Ritual
  • Liminal
  • Bridge to Spirituality and Culture
  • Family Centered
  • The Value of Doing

81
Types of Ritual
  • Continuity

82
Types of Ritual
  • Transition

83
Types of Ritual
  • Reconciliation

84
Types of Ritual
  • Affirmation

85
Creating Ritual
  • Arise from narrative
  • Objects are visible and symbolic
  • Planned and processed
  • Use primal elements (Fry)

86
The Possibility of Group Ritual
  • Arise from collective experience
  • Participants allowed to own the ritual

87
Grief Groups
88
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89
Support Groups
  • Validation
  • Ventilation
  • Respite and Support
  • Learn Coping Techniques

90
Grief Groups for Children
  • Reason
  • Size
  • Developmental issues
  • Leaders and co-leaders
  • Time issues - School Calendar
  • Intake
  • Open or close-ended

91
Grief Groups - Content
  • Should not focus solely on emotions
  • Other topic
  • Opening/closing rules and ritual
  • Processing the experience illness, death,
    funeral
  • Coping and support
  • Memories
  • Lessons learned
  • Sensitive to class and cultural issues
  • The value of doing projects
  • Empowering families through workbooks and handouts

92
Grief Camps
  • Bonding and Support
  • Problems
  • Homesickness
  • Discipline
  • Love triangles

93
Suicide in Children and Adolescents
94
Understanding Suicidal Behaviors
  • Ideation (Relatively Common)
  • Gestures
  • Attempts
  • Completions

95
Suicide Rate
  • Under-estimated especially in children and
    adolescents
  • Difference between suicide attempt and completed
    suicide
  • Risky and Self-Destructive Behaviors

96
The Suicide Rate Rises in Adolescence
  • Biochemical
  • Social and Psychological Stresses of Puberty
  • The Organization of Middle School
  • Social and Cultural changes

97
Adolescent Suicide
  • Three Roles
  • Prevention
  • Intervention
  • Postvention

98
Multiple risk factors make prediction of suicide
difficult
99
Adolescent Suicide Risk Factors
  • Poor family life
  • Poor problem-solving and coping skills
  • Special education at risk
  • Academic problems including perceived
  • Emotional problems
  • Substance abuse
  • Neglects appearance
  • History of accidents or self-destructive
    behaviors
  • Sexuality issues and fears
  • Less school involvement
  • Less active peer life
  • Bullied
  • Abused physically or sexually
  • Low self-esteem
  • Catastrophic loss

100
Types of Suicide
  • Psychotic
  • Depressive
  • Crisis
  • Anomic
  • Egotistic
  • Altruistic (Rare)
  • Fatalistic
  • Murder/Suicide
  • Autoerotic suicide

101
The Value of a Shared Protocol for Intervention
102
The Value of a Shared Protocol
  • Training in the protocol should include all
    school staff
  • Children may relate well and share with adults
    not perceived to be in authority

103
Assessing Risk CPR
  • Current Suicidal Plan
  • Prior Suicidal Behavior
  • Resources (Support) Available
  • Signs
  • Stressors

104
The Interview
  • Find a quiet place to talk
  • Ask directly about suicidal plans and thoughts
    open-ended questions
  • Focus carefully on the problems listen actively
  • Assess risk
  • Discuss strategies for dealing with the problem
    including parental contact, hospitalization
  • Mobilize the adolescents resources clergy,
    parents, etc.

105
The Interview (2)
  • Stay with the adolescent
  • Foster hope
  • Reach a contract and a plan
  • Follow up
  • Beware of the Flight to health
  • Avoid moralizing, scolding, reverse psychology,
    attempts to provoke
  • Share with colleagues and supervisor do not
    work alone

106
Assessing Risk Questions
  • On a scale of 1 to 10, how have you been feeling
    lately?
  • Assess changes in appearance, sleep, appetite.
  • Do you ever think of killing or hurting yourself?
    When? How often? What would you do? Are you
    currently thinking of killing yourself?

107
Assessing Risk Questions (2)
  • Do you have a suicide plan? What is it? (Assess
    how realistic it is.)
  • On a scale of 1 to 10, how likely is it that you
    would kill yourself? (Danger of 5)
  • Do you know anyone who has killed or attempted or
    completed a suicide?
  • What are you looking forward to? (Assess hope)
  • Assess resources

108
Intervention A Summation
  • Assess Risk
  • Decide Intervention Strategies
  • Referral (as related to strategy if
    hospitalization, process experience with student
    likely experience etc.)
  • Notify Appropriate Persons
  • Hand-off Student
  • Follow-up with Staff, Student (if so referred)
  • Follow up with Student (at return)

109
Suicide Postvention
  • Importance The Cluster Effect
  • Communication Chain Inform Staff
  • Media Plan
  • Inform Students
  • Review Life and Death (Avoid Scapegoating)
  • Identify those At-Risk
  • Set Up Counseling
  • Remember Staff
  • Careful Memorializing
  • Inform Parents
  • Monitor the Internet

110
Suicide Prevention
  • The best prevention may never mention suicide
  • Strategies for Schools
  • Curriculum Review
  • Teach Problem-Solving and Coping Skills
  • Enhance Self-Esteem
  • Traditional Approaches

111
Violence and Tragedy
112
Violence in Children and Adolescents
  • Social (media, availability of weapons, social
    status)
  • Cultural
  • Psychological
  • Lessened Family Supervision
  • Spiritual
  • Technology (Violent Video Games, Internet,
    Cyber-bullying)
  • The Socialization of Males

113
Reducing Violence in Schools
  • Zero Tolerance and True Threat
  • Zero tolerance vs. progressive discipline
  • Staff Training
  • Conflict Resolution
  • Anti-bullying programs
  • Supervision and policing
  • Bolstering community (peer-centered programs)

114
Creating School Community
  • Teach acceptance rather than tolerance
  • The importance of adult modeling
  • Issues of size and organization

115
Violent Events
  • Importance to have a lock-down and evacuation
    procedures along with regular drills
  • There is value in educating staff in creating a
    false all clear signal in case the
    administrator is under duress
  • Staff need to differentiate between true and
    false signals

116
Helping Children Cope with Tragedy Principles
that Need to Be Applied According to
Developmental Level
  • Acknowledge fear and other responses
  • Offer honest reassurance
  • Physical closeness (hugs, presence)
  • Keep communications open
  • Monitor media and Internet
  • Empower actions
  • The value of maintaining viable routines
  • Watch for danger signs and refer when necessary
  • Care for the carers!

117
Good Advice for Adults Too!
118
School Responses to Traumatic Loss
  • Communication Chain Inform Staff
  • Media Plan and Spokesperson
  • Inform Students
  • Validate and Explore Responses
  • Identify those At-Risk
  • Set Up Counseling
  • Remember Staff
  • Shape Group Response
  • Stakeholders and memorialization
  • Inform Parents

119
School Memorials Lessons from Columbine
  • It is a time-consuming process allow time for
    consensus and compromise
  • Columbine opened the committee to all
  • In public space, need to have policies to cover
    the use of religious, political, or potentially
    offensive statements
  • Memorial placed so it could be visited rather
    than confronted
  • Columbine used a pyramid of priorities in
    evaluating designs
  • Families of the those killed
  • Injured and families
  • Students and faculty
  • Community
  • In another memorial, issue of perpetrators
  • Bingham et. al., 2009

120
Debriefing
  • After events, it is important to debrief the
    incident with crises staff, guidance, and key
    administrators
  • Were procedures followed? How did the protocol
    work? What lessons were learned? What should be
    done differently?
  • Protocols also should be reviewed at the
    beginning of the year

121
After the Crisis
  • Monitor those who witnessed the event for PTSD
  • Remember PTSD needs treating by specialists

122
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