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Loss in a Paediatric Context

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1 Loss in a Paediatric Context
Grief and Mourning Loss in a Paediatric Context Display gear; Mix of grief books- include Wolfeldt, Swallowed by a Snake, Worden School resource books Siblings and grandparents books Journeys- mark grief how to help list

2 Who grieves? Parents Siblings Grandparents Significant others
School and activities friends A large community Care providers There are the obvious grievers and then there are also those which we do not have directly on our radar but who will suffer significantly through the death of a child. Some of these people may actually have never met the child but are affected by the poignancy and relatability of the loss. We need to be mindful of the ripple effect which provides the graphic of a stone dropped in a pond and the concentric circles which ripple out from it – remembering that the force of the impact feels much less of a gentle ripple than a tidal wave.

3 A Parent’s Loss; part of own sense of self connection to the future
unfulfilled expectations & ambitions some of own treasured qualities/ abilities source of love and acceptance sense of power and control over what happens to them social status and contacts Celia Hindmarch There are so many more losses than the physical being of the child albeit that this is the hardest to bear. Who that child was to the parents and who they were with that child will be missing The reality that bad things can happen to good people can leave a sense of vulnerability and ongoing fears particularly of illness which need careful support

4 “She was my child… and she still is
Don’t keep telling me what you think I am doing wrong. I’m doing it my way. It’s the only way I know how…” Beyond Words, Skylight, 2012 Show book!

5 Anticipatory Grief Normal mourning when facing a death
Can be as intense as grief after the death Varies in intensity May not occur especially in strong denial This is often an underestimated phenomenon commonly experienced in the time of a dying child, the intensity of it can actually be as devastating as if the child has already died.

6 Stages of Anticipatory Grief
1. realise death is eminent- sadness depression 2. concern for dying child- regrets, anxieties 3. rehearse death-concerns, fears, planning 4. imagine life afterwards; anniversary, stuff, grieving There have even been stages worked up about this which describe well what the evolving understanding and acceptance of the child’s prognosis leads to in a grief response. We can see here what our role might look like at each of these stages … discuss possible interventions; Help through finding healthy ways to express sadness and relieve fatigue as much as possible with respite Reassure about the team’s dedication and availability to help the child with symptom management, the family with care burden, and to set new goals and hopes for experiencing the best with their child Ensure good, timely discussion about their child’s death including asking the great probing question… so what keeps you awake at 0300, what are you thinking about? Help with funeral planning so that this becomes less worrisome, explore spiritual issues Talk about bereavement support and how it can come and go as the needs arise, help to build memorial activities which will be reassuring later- ensure that all memory making activities are offered as appropriate eg; photos, hand and foot moulds, painting, garden, adventures

7 Manifestations of Grief
Physical Emotional Spiritual Social Mental

8 Manifestations of Grief
Emotional Physical Crying, moaning, agitated, exhausted, sleeping changes, central constriction; dry mouth, tight chest, stomach ache, digestive issues, nausea, nervous laughter, more illness and accidents, sensory sensitivity Skylight2012 Shocked, stunned, sad, desolate, afraid, lonely, let down, overwhelmed, helpless, regretful, angry, guilty, relieved, sense of injustice, numb, empty, drained Kubler Ross taught us in the 70’s about the plethora of emotions which make up grief and we now look at these a as a soup of mourning ingredients which can come to the fore at any time in any order and recur in the same manner! The experiences are not all expressed in terms of emotional feelings but also physical and sensational manifestations, behavioural responses and cognitive thought pattern effects. These can be very overwhelming and leave mourners feeling stricken and isolated. The support for this is to help them to see this as a normal grief response and to learn how to deal with it.

9 Manifestations of Grief
Mental Social Blank, confused, forgetful, distracted, slow responses, difficult to make decisions, replaying, preoccupation, difficulty switching off, blaming, different world view, overwhelmed; too hard Needing to talk over, avoiding talk, wanting people or not, difficulty with commitments, changed reactions to touch, hurting others, differing family relations, risk taking Skylight2012

10 Manifestations of Grief
Spiritual Sensing the presence of the child who has died, asking why, seeking beliefs or turning away from them, praying or abandoning prayer, seeking nature, looking for meaning Skylight2012

11 “Inside this Shell of Mine” Nancy Bright
“Aside from offers of absorbent products, what do we have to offer each other?  My mother was a pragmatic girl who finally told me a safe place to grieve was lying on the floor.  She said that on the floor, ‘there’s no place to fall.’   She was right.  My body would collapse from the howling and it would curl itself up on its side on the wood floor like a salted slug, and the floor would not drop me.  I still feel the smooth wide boards of the kitchen floor against my cheek; its cool bones against my heated ones.” “Inside this Shell of Mine” Nancy Bright “Aside from offers of absorbent products, what do we have to offer each other?  My mother was a pragmatic girl who finally told me a safe place to grieve was lying on the floor.  She said that on the floor, ‘there’s no place to fall.’   She was right.  My body would collapse from the howling and it would curl itself up on its side on the wood floor like a salted slug, and the floor would not drop me.  I still feel the smooth wide boards of the kitchen floor against my cheek; its cool bones against my heated ones.” Nancy Bright

12 THE WHIRLPOOL OF GRIEF This diagram first appeared in the writing of Celia Hindmarch. It is a good illustration of the journey of grief. Interestingly the river of life flows on but it is not in the same place! The difference in the loss of a child is the TIME spent in the pond at the bottom and the mourning and acceptance phase which amounts to years.

13 Words of Loss Bereavement is what happens to you
Grief is what you feel Mourning is what you do Celia Hindmarch Art- Käthe Kollwitz “Woman with dead child”

14 Contexts culture community religion, spirituality male/ female
environment concurrent stresses history society It is important to remember the contexts in which people are grieving and how these impact on their experience and expression of loss. In terms of culture we need to mindful of what that means to each individual in a family as they may have different levels of uptake of their traditional culture and a new one. Religion does not equal spirituality and sometimes the ritual of religion has either a poignant reassurance or a painful source of angst. Many families go on extraordinary searches for existential connection and meaning which can take them to some dark places as they reflect on their child’s death and struggle with the Why’s and Where to Now’s. We will talk about some of the differences in masculine and feminine styles of grieving. It is important to remember the societal and cultural pressure put on the sexes to behave in a normative way according to their gender and that this does not always fit the person nor provide a healthy grieving pathway. Some environments are difficult from a practical perspective as far as grief is concerned- what if you live with many others and never get any privacy, what if you are a single parent and left alone? Stuff happens often in nasty clumps and we need to make sure that we help with concurrent stressors such as bills, funeral expenses, housing, return to work etc Your grief history may also shape how you grieve- what examples have been in front of you, how well you were informed, supported may shape your sense of what will happen now. Society is a fickle thing- we have a bewildering mix of two unhelpful attitudes to children’s deaths- Denial and Morbid fascination--- see next slide

15 And then there is Media Comic Relief stop !
This cross between being very very uncomfortable with death and fascination does not leave the bereaved in a good milieu. Think of Facebook and what that means in this setting When I post about my grief, your like is a silent nod of acknowledgement. I understand that you may have no words. While a heartfelt sentiment is best (even a <3 or typing my daughter's name is comforting), I know that you may be pressed for time or struggling with what to say. Clicking like makes me feel less alone.

16 Tasks of Grieving to accept the reality of the loss
William Worden Alan Wolfelt to accept the reality of the loss to work through the to the pain of grief to adjust to an environment in which the deceased is missing to emotionally relocate the deceased and move on with life Acknowledging reality of the loss Embracing the pain of the loss Remembering the person who died Developing a new sense of identity Searching for meaning Receiving ongoing support from others Two modern grief theorists with very similar “tasks” descriptors. These are not rapid timeframes either with many people taking up to a year to achieve the first task and then at least 3 years for the next ones. The latter tasks explain why many families get into bother more in the second and third year of bereavement rather than earlier.

17 Practical Advice for Mourners
Eat healthy, drink water, rest and sleep and exercise Talk to a trusted person, be with good people who care about you, be by yourself Ask for what you need, be honest It’s ok to grieve, cry, not cry, feel what you feel Talk with people who have been there, don’t cut off permanently Listen to music, go to nature, get creative Have massage, hugs, treats Keep safe, get help, forgive self, be patient Skylight2012

18 Transition A new sense of self connecting to the deceased
inner representation identification incorporation rituals, remembering “death is a transition not an illness” Phyllis Silverman This is the time where we need to be patiently alongside the mourner as they incorporate the reality of the loss with the reality of their need to live on and develop meaningful connections with the child who died which will sustain them through years of missing them. It is important to permit mourners to miss their loved one forever as they will also love them forever and they need this reassurance in a society where we still purvey that to grieve properly is to move on without- no parent is capable of this nor should they feel that they have to.

19 Reconciliation Making friends with grief
Carrying on without physical presence New sense of meaning and purpose Hope and commitment to future An ongoing journey This is the part that is able to be lived with

20 Advice Allow yourself to mourn Your grief is unique
Allow yourself to feel numb This death is out of order Expect to feel a multitude of emotions Be tolerant of your limits Talk about your grief Watch out for cliches Develop a support system Embrace your treasure of memories Gather impt keepsakes Embrace your spirituality Move toward your grief and heal Dr Alan Wolfelt Alan Wolfelt is a psychologist from Colorado in the US. He is a new generation counsellor who had written widely some very useful tools for grieving the loss of a child. This is his advice which was published on a Buddhist site on grief. Show book – A Child’s View of Grief

21 Risk factors who the person was nature of attachment mode of death
history personality social context concurrent stresses Art- grief tattoo by Rick Berry These factors point to how grief in general is assessed to try and identify people who are more at risk of complicated and enduring sorrow. It actually puts all loss of a child mourners into high risk by nature of attachment which does not necessarily that they will get into major problems but that we need to take extra care and long term vigilance. The story of the family is also impt- how did the child die?what are the personalities involved and do they have any concurrent mental haelth issues, social contexts and stressors, history of loos (not always negative- may have learned resilience)

22 Masculine Style Quieter, less visible
Less connected with past, more with future Less passive, more aligned with action Not as well accepted “When a woman feels lost, she tends to ask for help. When a man feels lost, he looks for a map” Tom Golden The masculine side of healing is not as accepted a mode of healing as the more traditional verbal and emotional expressions. It tends to be quieter and less visible, less connected with the past and more connected with the future; less connected with passivity and more aligned with action. As a consequence, I have noticed repeatedly that people who use a predominance of this masculine side of healing are suspected even by mental health professionals of “not really healing.” When a woman feels lost, she tends to ask for help. When a man feels lost, he looks for a map

23 Grandparents “a grandparent’s grief is like a fork with two tines—one representing the loss of a grandchild, the other representing the pain of your own child’s suffering.” M.H.Gerner-”For Bereaved Grandparents” Listen to your bereaved child Talk about your grandchild Consider your needs Survivor guilt & anger Hope for a better day The forgotten grievers- Margaret Gerner Listen to your bereaved child Bereaved parents need to talk about their child, and they need someone who will listen and not feel uncomfortable. It can be difficult to listen to someone who is ravaged with grief. And often, we can get too preoccupied thinking about what we are going to say to offer comfort. For many people, there is an overwhelming need to alleviate the agony of the grief. The motive is noble but the method is wrong. Rather than doing all the talking, allowing the brokenhearted person to talk can actually go further in helping to heal his or her spirit. “I worry about my son because sometimes he doesn’t open up about his feelings,” Barb says. “He’s trying to be strong for everyone else. He seems more comfortable talking to me through and instant messaging. I’m fine with that because it’s possible to listen through other forms of communication.” According to Gerner, if you really listen, you’ll understand, and listening is not filling every silence. Listening is the greatest gift you can give your child. “Sometimes it’s hard because I want to step right in and take care of everything for Teresa,” Cathy says, “but it’s not my place. There are times when there are no words, and that’s OK because it’s more important to be there and listen.” Talk about your grandchild Gerner says that talking about your grandchild tells your child that you care. If tears come, it’s because they’re sad, not because their child’s name was brought up. It can be painful, but talking about the child is healing and therapeutic. “We talk about Cassie all the time,” Cathy says. “You almost feel disoriented, but talking can help. You talk even though you know there are no answers. “It also helps to remember that there is no timetable for grief. Sometimes there are too many expectations regarding how or when someone is grieving. Don’t expect too much of your grieving child, his or her spouse, or yourself. “The hurt is so deep, you wonder how you’re going to climb out of it,” Barb says. “But you do, and you begin to see your child start to live again. That’s when you know there is hope with faith.” Consider your needs and those of your bereaved child A grandparent’s grief may not be recognized by his or her own child or others, but it is definitely there. It is vital for bereaved grandparents to give themselves permission to grieve and to focus on their own needs. Grandparents often are referred to as “the forgotten grievers.” They think they should cope better, have all the answers, control the situation and be a role model. But these types of expectations are unrealistic and unhealthy. Survival guilt and anger No one expects to outlive his own children, much less his grandchildren. And, according to Gerner, reactions of guilt and anger often are intermingled. In fact, grandparents often experience survival guilt because it seems unnatural for a grandparent to outlive his or her grandchild, and they often express the wish that they “could change places” with the deceased child. Then there are the haunting questions. “Why didn’t I baby-sit every time I was asked?” Why didn’t I spend more time with the baby?” “Faith really helps to sustain me during the frustrating time of asking why,” Barb says. “There are no answers to those questions.” Hope for a better day Bereaved grandparents learn to live without their grandchildren, but there always will be the “might have beens.” That is absolutely normal. “Cassie’s death has been absolutely devastating, but my daughter gives me inspiration,” Cathy says with admiration. “I try to be strong for her, but she is truly the strong one. Teresa and Mark are our guides and we follow them, instead of us trying to lead them.” “Sometimes, I wish I could bring Ryan back, but I can’t,” Barb says. “You think the suffering will never end, but with time, faith and support, you continue to make it through each day.” Each day, bereaved grandparents look for a little ray of sunshine to show on their bereaved child’s face. As time goes by and the healing process begins, a ray of hope will shine on your child’s face in his or her smile. There always will be a part of each of you that is gone, but in time you can learn to live with the part that is still there.

24 Siblings Charter We need to respect their rights to;
Bereavement Support Express feelings and thoughts Remember the person who has died Education & information Appropriate and positive response from school Voice in impt decisions Everyone involved Meeting others Established routines Not to blame Tell their story Winston’s Wish 2003 This is a special group of people- the brothers and sisters who mourn Charter for bereaved children Winston’s Wish has supported many thousands of bereaved children in the last 10 years. This ‘charter’ is based on our conversations with them. If we live in a society that genuinely wants to enable children and young people to rebuild their lives after a death, then we need to respect their rights to: B Bereavement support Bereaved children are entitled to receive the support they need. E Express feelings and thoughts Bereaved children should feel comfortable expressing all feelings and thoughts associated with grief, such as anger, sadness, guilt and anxiety and to be helped to find appropriate ways to do this. R Remember the person who has died Bereaved children have a right to remember the person who has died for the rest of their if they wish to do so. This may involve re-living memories (both the good and the difficult) so that the person becomes a comfortable part of the child’s continuing life story. E Education and information Bereaved children are entitled to receive answers to their questions and information that clearly explains what has happened, why it has happened and what will happen next. A Appropriate and positive response from schools or colleges Bereaved children can benefit from receiving help and understand from their teachers and fellow students. V Voice in important decisions Bereaved children should be asked if they wish to be involved in important decisions that have an impact on their lives (such as planning the funeral and remembering anniversaries). E Everyone involved Bereaved children should receive support which includes their parent(s) or carers and siblings and which respects each child’s confidentially. M Meeting others Bereaved children can benefit from the opportunity to meet other children who have had similar experiences. E Established routines Bereaved children should be able to choose to continue previously enjoyed activities and interests. N Not to blame Bereaved children should be helped to understand they are not responsible and not to blame for the death. T Tell their story Bereaved children have a right to tell their story in a variety of ways and for those stories to be heard, read or seen by those important to them.  Winston’s Wish 2003

25 What do Children Understand?
age environment experiences personality family coping From early thoughts which centered on the cognitive development profiles of theorists such as Piaget, we have broadened our contexts of assessing what children understand to include other equally influential factors such as- environment, experiences, individual personalities and how the child’s surrounding family cope (William Worden, P.R Silverman). That being said it is always a good guideline to use the developmental principles as a rough thumbnail sketch as to where a child’s cognition might be to understand what is going on… for example I know that a 3 year old does not have the cognitive development to accept that there is a place called “Heaven” which you cannot actually visit, his concrete thoughts lead him to believe that Heaven is like say Melbourne- a long way away but a physical existance. Neither can he conceptualise that death is a permanent separation. Hence he is ambivalent that Nanna Paulie died because he thinks that we can go visit her for a coffee in Heaven and that she’ll be back soon anyway! He also found the dichotomy of Paulie being “up in heaven” and simultaneously buried down in the ground somewhat challenging! Try looking up cognitive development and the concepts of death and illness- they are a great guideline! Lois Tonkin’s book “Helping the Hurt”, and “Everybody Hurts Sometimes” are excellent resources in working with grieving children. Sara Fleming, NP Sara Fleming, NP

26 Concepts of Death Separation (age 5)-dead people do not co-exist with the living Causality (age 6)-death is caused by something, be it trauma, disease, or old age Irreversibility (age 6)-a dead person can not ‘come alive’ again Cessation of bodily functions (age 6) Universality (age 7)- all living things will die Insensitivity (age 8)-the dead can not feel fear or pain RCH website from this we can see that the simple concept of death itself develops in stages and that being caught in between some stage could present a problem... For example if you understand that death is permanent and irreversible but you haven’t “got” that the dead cannot feel fear or pain then you might well be very very concerned about cremation! Sara Fleming, NP Sara Fleming, NP

27 What do Children Understand?
Environment Physical Social Cultural Emotional Where a child lives and the potential comforts and concurrent stresses may influence their grief responses. There may be accompanying changes of living environment which are causing stress themselves and then one might need to look at ways to make this area more comforting and familiar such as moving the child’s stuff there, finding old pictures and teddies, are there photos around which the child would like to see? The cultural and religious factors will be an influence on understanding because these form a framework by which things are explained and interpreted. For example- does the child come from a Christian background where the analogy of heaven is their reference point for what happens to someone when they die- do they understand this, are they confused by it, is it of reassurance? Does their culture generally talk about those who have died or is this forbidden- in the aboriginal culture one never speaks that persons name again. As a health care provider we need to discover this about the child we are supporting so that we understand their environment and can work with it. Sara Fleming, NP Sara Fleming, NP

28 What do Children Understand?
Experiences Personality Life journey Responses to stress Sex Capacity to adapt Bonding How common is death in this child’s environment and does this help their grief work- for example, if the child’s family have experienced many deaths then perhaps they have a growing resilience or maybe the opposite- an accumulation of unresolved loss. The child’s own personality will shape what they understand and how they express this. It may be easier to talk about another stressful event from the past with the child or their carer to get a perspective on how they have coped in the past. The influence of male and female styles of grief will often be evident in very young children who look to their elders for a lead on how to behave. For example I have had to encourage father’s to show their grief in front of their sons so that they don’t think that it is not ok to cry! Again the personality of the child may mean that overt displays are not comfortable for them and they need help to explore other means and places for this. Tom Golden writes well about the needs of male children. Whom the child seeks for support may also be a factor in their understanding- is it possible that the one person who communicated tender information to them is not available? If so- who is the next best? It is also common for children to shield the loved ones around them from the more intense expression of their grief as they sense that this distresses them. This is where the role of an independent counsellor or family friend less affected by the loss may be invaluable. Sara Fleming, NP Sara Fleming, NP

29 What do Children Understand?
Family Coping Extent of crisis Collective behaviours Communication style Alliances Resources The family surrounding a child are paramount to their understanding and expression of grief. How a family copes will be dependent on the extent and impact of the crisis –from the family’s perception (not ours) How they behave in response to this What are their usual communication style? Open? Frank language? Child respect and involvement? Have they formed new strenghts and alliances as a result of the trauma? What resources of support are really available to this family and are they using them? Sara Fleming, NP Sara Fleming, NP

30 “I’m upset”; cry, thumb suck
Age Grief Response Companioning Infants and Toddlers Baby-2 years Loss= absence “I’m upset”; cry, thumb suck Change in normal patterns in sleeping, eating, fussing Physical comfort Accept, get routine Preschoolers 3-6 years Death may be thought of as temporary and/or reversible May not understand new feelings, unable to verbalise Ask ? About death over and over. Reenact death in play Regress- potty, sucking, baby talk Provide terms for feelings Answer concrete & lovingly. No half truths Death play ok, join in and offer guidance These are normal. Offer presence and support Grade Schoolers 6-11 years Express grief primarily through play May “hang back” socially, scholastically May act out because they don’t know how else to handle their grief Use “older kid” play therapy Permit to take time to mourn, give them time Offer venting alternatives. Support groups can be helpful. Alan Wolfelt-Companioning the Grieving Child

31 May protest the loss by acting out/ withdrawing
Age Grief Response Companioning Adolescent 12 years and up Understand death cognitively but are only beginning to grapple with it spiritually May protest the loss by acting out/ withdrawing May feel life has been unfair to them, act angry May act out a search for meaning, test his own mortality Tolerate if no-one is being harmed. Withdrawal is normal short term only. Normal egocentrism. After he has had time to explore this, encourage to consider the impact on his larger social group. Teens explore the “why” about life and death. Encourage search unless it may harm Alan Wolfelt-Companioning the Grieving Child

32 When a sibling dies Layers of loss Survivor Feelings an ally
Sara Fleming, NP When a sibling dies Layers of loss Survivor Feelings an ally a companion a carer, a dependent an identity innocence routine, normality balance Guilt Relief Fear Confusion Wolfelt There are many more losses in a death than the physical person Who this person is to the child will be an important key to how they might grieve them and what will be helpful to them. For older children especially, their innocence of the safety of life ongoing is also lost and the knowledge that the “shit happens” fairy has been to visit them can make them feel insecure that she could easily return. Death effects distress and asks for rituals which muck up routines, maybe this has also been true through an illness preceding the death. We know that children thrive on routine so care may be needed to restore a sense of normality. The death of a sibling is often among the most traumatic events in a child’s life. Siblings’ normal feelings for one another include not only love but anger, jealousy and other ambivalent emotions. When a sibling dies, the surviving kid(s) sometimes feel: Guilt (because at one time or another, they may have wished the sibling were gone). Relief (because now they don’t have to share or vie for attention). Fear (because now they know they could die, too). Confusion (because they’re unsure if they’re still a brother or sister). All of these feelings are normal. You can help by listening or observing non-judgmentally as the child expresses them. Carpe diem: If the child’s sibling has died, help him write a poem in the sibling’s honor. Have him write the sibling’s name vertically on a piece of paper, and then begin each line of his poem with the corresponding letter. Sara Fleming, NP

33 Behaviour acting out withdrawal disobedience insecurity inattention
sleep disturbance appetite changes sensitivity, fears So would we be surprised if we saw this?!! Certainly not! Some children become more quiet and absent themselves from social events and friends Some become unnaturally naughty , many in an attention seeking manner Regression of developmental stages is not uncommon for example- thumbsucking, incontinence, passionate need for particular comfort objects. Most children suffer a degree of inattention which adults would also describe as concentration difficulties- this can be a particular problem with schooling. Sleep disturbance with difficulty going to sleep, nightmares, bedwetting may also occur. Special attention to extra relaxation and reassurances at night will be important for these children- what would be examples of this? Children may also suffer appetite changes either increased or decreased In amongst all this it is important to note that generally children cannot hang on to one particular emotion for long and so their intense sadness or anger may be sudden in onset and then disappear to be replaced by laughter and play . What this reassures us is that these children can be distracted and comforted to go on and lead happy lives. Sara Fleming, NP Sara Fleming, NP

34 What helps? Information, answer questions involvement, funeral etc
discussion about loss normality, play special time, meaningful memory making and rituals peer and school support external support working with the parents/carers Information about what is happening in simple language and small amounts is very important. We know that it is better for the child to have the truth especially in answer to their questions than to risk a sense of betrayal or the wrong impression from their imagination. Lauer et al researched the surviving siblings of children who died at home and found that their grief adaptations were more healthy than those whose sibs died in hospital- much of this was attributed to their witnessing of the reality and having a role to play. Most children will want to go to the funeral of a loved one- if culturally appropriate this is an important place where the child needs to have a choice and to have someone there with them specifically to look after them at the funeral. Children need avenues to express their grief and also to be distracted from and engage in normal daily life where they will feel safe. Peer support and return to things such as school and childcare will be reassuring. Use of art, puppets, clay and non-verbal outlets may be very important. Children need to develop their own special memories about the person who died and their feelings and experiences. External support from someone who is not so affected by the loss may be a key to their adaptation and mourning- this may be a counsellor, teacher, family member or friend. It’s very important to help the carers of these children to support them, ultimately they will be the main people these children need. Ideas and written information about how children grieve and what avenues help is useful. Sara Fleming, NP Sara Fleming, NP

35 Memory making and rituals
Treasure box Plant tree, garden Christmas decoration Drawing Photo collection Touchstones Poetry, music Star naming Conversation Ongoing activities Anniversary actions Special places Mealtimes Sad, mad, glad space activities This may include finding treasures (treasure box example) which remind them, developing a photolog, planting a garden, naming a star

36 Talking with Children our own anxieties, helplessness
talking to becomes with repeat information reassurance, trust, security right place, right time, right person not what you say but how you say it! First of all- deal with your own anxieties and get prepared with information about the child and family, support for yourself and development of the scenario. Try to remember that you are entering their space Gently repeat information- this may also mean understanding well yourself what info has already been shared with them. We cannot always succeed first time to work with a child as far as depth of discussion etc. It really is dependent on the time, place and person. Much of the time there will need to be some mucking around just to build a trusting relationship. Watch the place bit- where are you meeting with this child- is it conducive to talk, are they comfortable? Sara Fleming, NP Sara Fleming, NP

37 How you say “it” talk at eye level
speak directly to and with the child avoid confusing language and double meanings avoid cliches, platitudes keep it short and simple- repeat check the child’s understanding be truthful & honest- share your feelings keep them informed & talk open - Earl Grollman 1990 Earl Grollman is a well respected writer on the perspectives of children who are greiving. His books are great! Sara Fleming, NP Sara Fleming, NP

38 Carpe Diem Alan Wolfelt
Acknowledge the reality of the loss Feel the pain of the loss Remember the person who died Talk about the physical reality of death- may sure they understand how and why the person died Next time they cry, hold gently and let then cry as long and hard and often as they want to Invite to share a memory, or ask to show photo of who died then tell you what was going on when pic was taken

39 Carpe Diem Alan Wolfelt
Develop a new self-identity Search for Meaning Receive ongoing support from caring adults Include Child in Funeral Ask child to draw 2 pictures; of his life before and after the death, talk about differences. Share your beliefs without pressure for child to believe what you do. Create a plan to help, mark dates to contact and spend time, mark important dates If funeral done, talk about ceremony answer ?, discuss ongoing way to honour who died.

40 Carpe Diem Alan Wolfelt
Help child choose a keepsake Give permission to find comfort in linking objects Consider child’s relationship to the person who died Talk about keepsakes, ask about a chosen one’s significance or help plan to chose/ procure one Do they have one? Talk about this, affirm need to have and hold this. Think about this from her point of view. Set aside your thoughts and feelings and enter her world as you consider this point.

41 Schools inform of child’s loss identify others at risk
provide simple information with permission support staff written resources + online develop memorial/ritual set up liaison with education department supports Most schools will have their own support services and will simply need encouragement to activate these. They all have access to the Seasons Loss and Grief program which is usually an optional part of the curricula. Information about the grieving child and their particular needs is best shared with the school so that they may make adjustments as required. This might include; cutting some slack with deadlines, in-class support, setting aside special time with the child 1:1 and nominating a close person to the child for them to access anytime in school. Show school resources Sara Fleming, NP Sara Fleming, NP

42 Others Extended Family, friends Facebook contacts Neighbours
Community groups Sometimes need some help here Refer to journeys dos and donts list

43 Risk Factors Nature of the Loss Features of Child
traumatic, Unexpected Features of Child Psyche disorder, multiple losses, adolescent,<5years Nature of Relationships Ambivalent, low family support, father of teen boy, mother of young child Aranda.S, Milne,D, For complicated grief we know the certain factors put children at higher risk. How these may manifest are; Persistent; aggression Denial of the death Pronounced deterioration at school Expression of low self esteem Withdrawal from friends/family Nightmares, not sleeping Physical symptoms- abdopain, headaches, illnesses Weight loss ++ Negative thinking of future Suicidal ideation They require referral to professional counsellor/health provider for assessment Sara Fleming, NP Sara Fleming, NP

44 Resources NALAG, Grieflink Child and Youth Health website
Sara Fleming, NP Resources NALAG, Grieflink Child and Youth Health website SIDS and Kids, SANDS RCH Palliative Care website Compassionate Friends Skylight, NZ Starbear (S.A.), Anglicare Loss and Grief Centre Journeys folder- PallCareAus website Disease base associations There are lots of resources both in Adelaide and through the internet Also can now get 5 sessions on medicare with a GP referral to a psychologist Sara Fleming, NP

45 Books 13/04/2017 Sara Fleming, CYWHS 13/04/2017
Good bookshops such as the COPE bookshop, Koorong, usually stock books even mainstream bookshops such as Dymocks and Angus and Robertson seem to be having a good range now. Sara Fleming, CYWHS

46 Questions If ever there is tomorrow when we’re not together… There is something you must always remember. You are braver than you believe, stronger than you seem, and smarter than you think, but the most important thing is, even if we are apart… I’ll always be with you. A.A.Milne

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