This seminar was held on Tuesday 15 June 2010 at Tally Ho police training centre in Birmingham, supported by Fentons Solicitors LLP.
Children and sudden bereavement: an academic overview
Cathy Keeler, deputy chief executive, Brake
Academic/ theoretical overview
Children are often described as ‘the forgotten mourners’ because they are frequently excluded from having a full and active role in the grieving process. Children have a right to know what has happened, and a right to grieve and there is a wealth of academic research to show that it is much better to tell children things than to keep them in the dark.
Children grieve in different ways at different times. They may cry, get angry, be quiet, be noisy, talk about the person who died, not talk about them, and play or behave as though nothing had happened. They may suddenly switch from one reaction to another. All these reactions and many more are natural.
Children’s health may be affected by the stress of sudden bereavement. Stress lowers the immune system, making them vulnerable to illnesses, aches and pains. They often complain of headaches, tummy aches and non-specific aches and pains. These aches and pains can sometimes be the child’s way of describing their emotional distress.
It is worth recognising that – particularly with a sudden bereavement – children may not have access to their usual support from their usual carers. This may be because a carer has died, or is trying to cope with the shock of a sudden bereavement themselves. There may or may not be support for the child at their school.
Grief at different stages of development
Children’s understanding of the concept of death and what is happening, their experience of loss and reactions will depend on many factors, not least of which is their stage of development. As a general guide:
- 0-2 year olds have a limited understanding of the concept of death and permanent loss, but even very young children do experience loss, particularly when a primary caregiver has died;
- 2-5 year olds have some understanding of the concept of death, but tend to think it can be reversed. They try to make sense of events but are easily confused by explanations;
- 5-9 year olds have a greater understanding of the permanence of death, but may struggle to understand when the person who has died is not old or sick. They tend to be curious about death and the rituals surrounding it and often ask many questions. At this age, they can be particularly sensitive to the remarks and reactions of other people;
- By the age of 9 or 10, most children have come to understand that death is inevitable – we all die at some point – and final.
The shock and stress of a sudden bereavement can mean that children temporarily regress to an earlier stage of development. A child who is suddenly bereaved may also re-experience the grief of bereavement as reach different developmental stages and their understanding of what has happened develops.
Common feelings in bereaved children
Common feelings – as explained in Brake’s Amy & Tom book ‘Someone has died suddenly’ – may include: sadness/crying; anger; guilt; isolation; not being understood; and a lack of energy and enthusiasm.
Children and sudden, traumatic bereavement
Sudden, traumatic bereavements have special features that need to be taken into account when supporting bereaved children.
- Children may have witnessed the death, or events leading up to it. They may have been at risk of death or injury themselves. This may have provoked intense fear.
- A death is particularly likely to be traumatic if it is a sudden death of a close relative and/or an untimely death.
- There may be secondary losses for the child associated with the death. They may have new adult carers and/or a new home. The comfort of familiar routines may be upset.
- Traumatic bereavements can sometimes result in serious health problems, including Post Traumatic Stress Disorder.
What professionals caring for children can do to help
Professionals caring for children who are suddenly bereaved can help by creating a supportive environment in which children can:
- express feelings and thoughts
- ask questions about what happened and be given age-appropriate information
- have a voice in important decisions relating to their own lives
- remember the person who died
They can also:
- provide general support and signposting for the child and whole family;
- encourage parents/ carers to give children opportunities to ask questions and answer them honestly;
- suggest activities that encourage children to express their feelings and signpost resources from relevant organisations
Supporting suddenly bereaved children: a personal perspective
Karen Scarrott, bereaved mum and Brake volunteer
Karen talked about the impact of sudden bereavement on her three sons: Daniel, Joseph and Ben. Their sister, Karen’s 14-year-old daughter Jade was run over by a pick-up truck on 23 June 2004 and died in hospital two days later. At the time, Daniel was 17, Joseph was almost 16 and Ben was 12.
Karen felt the family was let down by a number of agencies, including:
- social services – Jade had ME and a family support worker from social services was looking after her when she was run over;
- the police/ social services – as social services were already involved in supporting the family, due to Jade’s ME, it was decided that social services (rather than the police) should inform the boys that Jade had been injured. This had severe consequences for Ben, who was left at school in ignorance of what had happened and later suffered panic attacks at school, fearing for the safety of his family.
- Birmingham Children’s Hospital, which did not have good facilities for families in the intensive care unit and had not provided holiday cover for the family support worker (following complaints from Karen, the hospital made significant changes to the facilities in intensive care and its policies on support for families).
Karen’s advice on supporting suddenly bereaved children included:
- giving them information and letting them make their own choices – Karen let her boys choose whether to visit Jade in intensive care and whether to go to the funeral (and their role in it);
- being understanding of mood swings and reluctance to ‘join in’ with family events – appreciating that everyone feels and acts differently from each other and at different times
- being guided by the child as to the support they need – e.g. Karen decided to home-school Ben when he couldn’t cope with panic attacks at school
- not necessarily expecting things to ‘get better’ with time – it also brings new sadnesses, with Jade not there for significant moments in the boys’ lives, such as birthdays, Christmases and the arrival of her nieces and nephews.
Sudden, traumatic childhood bereavement and PTSD
Dr Manda Holmshaw, clinical director, Moving Minds
Sudden, traumatic bereavement and possible psychological effects
The effects of a sudden, traumatic bereavement on a child depend on a number of factors, including: pre-existing vulnerabilities; the age/development of the child; resilience factors; and the availability of “support”.
The possible psychological effects of a traumatic event include:
- Normal stress response and recovery
- Posttraumatic Stress Disorders
- Acute Stress Disorder (up to 4 weeks)
- Post Traumatic Stress Disorder (PTSD)
- Phobias (car travel, school, darkness, being a pedestrian)
Diagnostic criteria for PTSD:
A. Exposure to a traumatic event
B. Recurring intrusive recollection of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness
D. Persistent symptoms of increased arousal – physiological hyper-reactivity
- Acute or chronic
Even young children can experience psychological trauma and PTSD, often with long-term and disabling consequences. Delay in referral for treatment is common, but trauma-focused psychological therapy is effective for children as well as adults. Trauma-focused cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing (EMDR) can be rapidly effective, even when symptoms have been longstanding.
Case study: Alan, aged 4
Alan had been living abroad with his father since the age of two, as his mother was a drug addict and neglectful. His father was killed in a road crash on a rainy night. Alan was referred for treatment by his aunt (who was caring for him) because she was “at her wits’ end”. Alan was displaying sleep problems, excessive clinginess and destruction of toys. His Aunt was unable to work and suffering grief and post-traumatic stress from her own bereavement in a previous road crash.
Treatment for Alan included:
- Advice and support for his Aunt on her own bereavement; and understanding and responding more effectively to Alan’s needs;
- Support in stabilising the general situation, including contact with Alan’s mother, guardianship, etc
- 5 sessions of age-adapted trauma-focused treatment with Alan, assisted by his Aunt
Key points from this case study and others outlined by Dr Holmshaw included:
- Even young children can suffer PTSD
- Play may be a form of re-living the trauma
- A carer’s ability to understand and meet child’s needs is crucial – and may be impaired by stresses (e.g. bereavement, financial, employment, emotional and mental health issues)
- Treatment must address needs of parent/carer as well as child
- Wider “systemic” issues have important impact on recovery rate for child
- “Absent” death is challenging and may lead to fantasy self-explanations
- When a child is referred for treatment or psychological trauma, it is always important to enquire about their carer – treating a carer’s mental health problems may be key to meeting the child’s needs.
Children who survive trauma and have PTSD often also suffer from other disorders, especially:
- Conduct disorder
- Substance misuse
What helps children recover? Why do some people develop disorders, others not?
Risk factors for PTSD
- Perceived threat and high levels of distress
- Being female
- Anxiety and depression symptoms
- PTSS in parents
- Poor maternal mental health
- A previous history of traumatic experience
- Previous emotional and behaviour problems
- Younger age
- Safety, security and support
- Sensitive response to needs (adjust for age, understanding and individual circumstances)
- Information and practical support
- Familiarity, routine and consistent management
- Contact with parents or a familiar adult, a favourite toy
- Opportunity to express feelings and share experience.
- Help and support for carers – e.g. school
- Resilience: better outcomes are associated with
- feeling safe and secure,
- older age,
- ability to make sense of experience,
- availability of comfort and understanding
- routine, familiarity and consistency
- Recognise the psychological vulnerability of children
- Talk to children about what they have experienced
- Refer for assessment if problems persist beyond 4 weeks
Promoting rapid recovery
- Be aware of the potential psychological impact of traumatic events on children and other members of the family – raise awareness of the difference between a “naughty” child and a traumatised child
- Help child to express and make sense of the experience and concern about the parent
- Support parents and carers in understanding and meeting the child’s needs. Parents are often so ridden with distress and guilt about the child’s position that they may avoid tackling the child’s distress
- Positive experiences, distraction through different activities, keeping to a containing structure
- Early intervention is crucial in preventing chronicity and behavioural problems causing secondary consequences.
- Refer early for specialist psychological treatment.
Support work with suddenly bereaved children in the school setting
Pete Brayshaw, trainer, Edward’s Trust – Sunrise
Pete gave the following practical advice for anyone supporting suddenly bereaved children in a school, or similar setting.
Before a return to school
- Check with the family and child how they want to handle the situation
- If you can - find out what the child knows about what happened
- Will the child go to the funeral / see the body?
- Consider how to tell staff
- Consider how and what to tell the other children and parents
- Are there other agencies that are or could be supporting the child?
- Who will be supporting the child in school?
Return to school
- Have somewhere private where they can go if needed
- Allow them time to talk whenever it is needed
- Talk about the person who has died to show it is ok to do that
- Talk about emotions and share in an appropriate way
- Allow the child to express their emotions if and when they need to
- Check what they know about how the person died
- Check what their understanding of death is – this may change over time
- Answer questions as honestly as you can
- Notice any changes in mood or behaviour as signs of upset or stress
- Notice if anything in particular causes these changes
- Remember birthdays, anniversaries and any significant dates
- Review the support given on a regular basis
- Consider if specialist support is needed
- Continue to monitor over time
He also spoke about possibilities for schools helping suddenly bereaved children create ways of remembering a loved one who died; and ways that the whole school could create memorials if a pupil, or sibling of a pupil dies.
Children’s dreams and nightmares: the impact of trauma when children sleep
Brenda Mallon, bereavement counsellor/ author, Brenda Mallon Bereavement Training
Trauma occurs when a sudden, unexpected or completely extraordinary event overwhelms the child’s ability to cope and which creates feelings he cannot control. Frequently feelings of helplessness swamp the child and there are no obvious ways that the child can make a difference. These feelings find their way into the dreams and nightmares of traumatised children.
Deep fear may surface in dreams following traumatic experiences. Though the actual cause of death may not be re-enacted, it is often expressed in a symbolic way. Some examples are: being overwhelmed by a flood or tidal wave; being attacked by people or wild animals; being caught in a fire with no obvious escape; being in a plane which is about to crash; being caught in a hurricane. The underlying sense of the dream is that events are beyond the control of the dreamer.
After trauma children need to gain emotional mastery. In dreams this may involve the child in fully exploring the dream images, correcting mistaken ideas, finding different endings for the dream and drawing, painting or writing about it. Brenda showed several examples of creative work that she had done with children to support them in doing this.
Brenda advises that there are a number of things a caring adult can do to help. The most important thing is to be a good listener who is non-judgemental and willing to help the child express his thoughts and feelings.
- Listen to the story of the dream
- Don’t put your interpretation on the dream. The dreamer is the one who knows what the dream is about.
- Don’t dismiss the dream as silly or unimportant, Dreams are not ‘right’ or ‘wrong’, they are expressions of the inner world of the child.
- Reassure the child that her disturbing dreams do not mean she is ‘mad’. Help her to realise that the dreams are a way of coming to terms with her loss.
- Ask supportive, open questions to explore the dream: Who was in the dream? How did you feel? If the child was frightened, was there anyone who helped? If there was no one, could they think of someone who would have helped?
- Allow the child to go at her own pace, don’t force her to go on talking when she wants to stop.
- Help the child to make links to waking events. If she was frightened by a dog in the dream can she recall being frightened by a dog when she was awake?
- Some children believe that if they talk about a dream event it will happen in waking life. Help children to understand that dreams communicate feelings and ideas and help you to understand yourself better.
- Respect the child’s right to confidentiality. Never talk about a child’s dream to another person unless you have their permission.
- If the child wants to, encourage her to draw or paint the dream, then look at the image and talk about it. If there was a frightening monster, could she think of anything or anyone who could help in the dream? If so add them to the image. She might want the offending monster to be cut out or trapped in a strong cage. The aim is to generate positive responses that empower the child.