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, Amazon.com 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