American Hospice Foundation, Washington DC, USA

Children's Complicated Grief: A Case Study

By Linda Goldman

Complicated Bereavement in Children

In traumatic grief, fear can often override the grief response.

When children experience a loss, they begin to work on and process the now well-identified tasks of "normal" grief: (1) understanding (2) grieving (3) commemorating and (4) going on (Sandra Fox, 1988).  In complicated grief, other emotional issues such as fear or shock can dominate, acting like a wall between the child and his or her grief process.  Girls and boys may no longer have direct access to working on and processing these common tasks of grieving.  Before these young people can access their grief process, this barrier must be eliminated.

It is as if the traumatic emotional issues have become frozen in the psyche as an impenetrable wall that prevents children from accessing underlying grief.  The task of caring adults is to help them melt down their frozen state in order to begin to grieve naturally. A safe environment to express thoughts and feelings is essential.

In complicated grief, the complex issues and grief can become merged in the child's mind as one single event.  Children are sometimes unable to separate the circumstances surrounding the loss from the loss itself.  If fourteen-year-old Ed’s older brother was murdered in a ride-by shooting, the murder and the death of his brother may become fused as a single idea.  Ed might not be able to tell a friend that his brother died because of the shame or anger about how his brother died.

Categories Contributing to Complexities in Grief

A situation such as suicide, homicide, AIDS, violence, and abuse often create complex grief issues that need to be addressed.The following are categories that contribute to complicated grief (Goldman, Breaking the Silence, 2nd Ed., 2002).

Sudden or Traumatic Death: Sudden or traumatic death such as murder or suicide can immediately create an unstable environment for the child.  Sally fears, "If my dad can be murdered walking down the street, the same thing can happen to me."  The terror, shock, and confusion from this type of death can manifest in a frozen state of overwhelming feelings that might inhibit grief. Social Stigma of Death: AIDS, suicide, and homicide often carry a shame and social stigma that can cause children to withdraw into isolation and repress feelings. Tom's secretiveness about his brother's death from a drug overdose may complicate his natural grief process. 

Multiple Losses: Children may be plagued by fears of abandonment and self-doubt if they experience multiple, reoccurring losses.  Amy’s dad abandoned her at age four. She may re-experience this loss along with her present grief at age eight when her mom was killed in a car accident. Amy could experience excessive nightmares and worries from processing both grief experiences together.

Past Relationship to the Deceased: When a child has been abused or neglected by a significant person who has died, secret feelings of relief or anger may emerge and feel shameful.  Kathy may feel relieved that her uncle who was sexually abusing her has died.  She can't speak of this because she is too ashamed.  Family secrets may remain locked away after the person has died, also locking away the path towards processing grieving.

Grief Process of the Surviving Parent or Caretaker: Adults are role models for children.  How the surviving adult processes grief can have a direct effect on the child.  Sam has never seen his dad cry over the death of his mom.  He feels he must "act like a man" and not cry too, just like his dad. If the adult doesn't express feelings of grief, children are not given permission to share their feelings of loss.

Signs of Complex Issues Complicated grief is characterized by an increase in the intensity, frequency, or duration of signs. Children can express the amplification of these feelings in the following ways:

DENIAL:  Six-year-old Alex did not show any emotions about the death of his older sister and outward grief appeared absent for over a year.   Alex kept telling his friends and family that he believed his sister would come back.

AVOIDANCE:  Seven-year-old Steven witnessed his dog, Harry, being run over by a truck.  After two years he wouldn't go to the home of a friend who had a dog.  He wouldn't go to the movies if they were about dogs, and he refused to look at family pictures with Harry in them.  He said it hurt too much.

PROLONGATION: Ten-year-old Alice felt rage and deep sadness after the sudden death of her mom.  If, as a thirty-year-old woman, she is still filled with the same intensity of grief feelings about her mother's death, her childhood loss has remained a trauma long into adulthood.

SUBSTITUTION: Susan's father was murdered when she was sixteen-years-old.  Following his death, she began to go out every night with a fast crowd of friends.  She indulged in drugs, shoplifting, and developed patterns of overeating as forms of diversion.  All of these symptom patterns can be expressed acutely with sharp ups and downs or chronically at a lower level of intensity but with more consistency.

The meltdown process allows children to re-experience their feelings that were frozen at the time of the loss by some type of deep trauma.  Caring adults need to create a safe environment whereby the children have the space to remember what has become denied or repressed. Caring adults can offer permission to feel the tears and fears, terror and rage, and bring these trapped feelings into the light of day.

Adam: A Case Study involving Complicated Grief

Adam was a seven-year-old child whose dad, Carl, had been murdered in a street fight while Adam was at school.  His dad had abandoned his mother and him when Adam was age two. Carl's visits were infrequent and explosive, with Carl often going into an alcoholic rage of physical and emotional abuse that terrified Adam and his mother.  These outbursts of violence remained silently buried in Adam after his father's sudden death.

Adam was referred to counseling because of a history of repeated emotional outbursts in school, inability to stay in the classroom, and poor school performance and conduct.  He had moved five times before his father's death and had lived with his aunt during his mom's illness.  Adam's behaviors fluctuated from rage towards teachers and peers to kindness and helpfulness for his teachers and friends.

Melting Down Frozen Feelings Because Adam was unable or unwilling to talk about his father's death or his life before his death, projective techniques were used to help unlock hidden feelings.  Adam was asked to draw a picture of life with his family before his dad died.  He drew only stick figures, with a large figure screaming, "Shut up and get out of my way!" and a very small figure with a big tear saying, "Help me."  His sadness and feelings of being overwhelmed by his dad were represented in this picture.

Telling stories and playing games established rapport.  Adam liked to create stories and reproduce them with toy figures.  Polaroid pictures of his work were taken and his story and the pictures were left for others to see.  By projecting his feelings onto drawings and written work, Adam was beginning to safely place them outside of himself.  His photographs became a tangible representation of feelings that he could share with others.  He would frequently ask if there was feedback from any other children about his work, and he seemed to take pride in their responses.

A Contract

Specific single goal behavioral contracts were made with Adam.  The following was one of our first contracts:

THE ADAM CONTRACT

I agree to raise my hand in math class when I want to say something for one week.  If I get frustrated I can tell . . .

  • My Teacher
  • Linda
  • The Guidance counselor
  • My journal

I will get the treat of my choice at the snack bar from Linda at the end of the week.

Adam         Linda

Adam's math teacher reported that there was a significant improvement in his ability to raise his hand in class when he wanted to speak within the next few months.  The teacher initially found he needed to create a meaningful reward for Adam on a daily basis as well as my weekly snack bar treat.  We then began to stagger his rewards further apart.  Adam reported he felt comfortable telling the guidance counselor or writing in his journal when he became frustrated.  He called me on two occasions to talk about frustrations at school.

His behavior varied from session to session.  Sometimes he would come to the office enraged at his day care provider.  "I hate that bitch!" he would repeat over and over again as he punched the punching bag in the office.  Other times he was withdrawn and speechless.  He began drawing a picture of a super hero. I asked him what the super hero could do.  "He has the power to make people be good - to make people be nice. He can hypnotize the bad people and make the sun stop."

Dissolving Anger

Adam is clearly a child exhibiting anger in many forms. His outbursts towards children and adults, his use of profanity, and his storming out of situations in which he is uncomfortable, are a few of many examples of anger projected onto other situations or people.  We can help children like Adam vent angry feelings in a safe environment without hurting himself or herself or someone else.   Adam once created clay figures of his dad and himself, with his dad yelling at him to go to bed.  "I hate you!" he screamed as he pounded and pounded his dad figure again and again until it was unrecognizable.  "I wish you were dead!"  Children can create clay figures and dialogue their anger with them or choose to destroy the figures.

In another session, Adam was furious at the principal of his school for suspending him for walking out of class.  He took a pile of magazines and began ripping them up all over the room.  He ripped the pages furiously until the room was covered with them.  Some of his anger had begun to be released.  He was calm enough to talk about what happened.   "I hated to stay in the room!  My math was too hard.  I couldn't do it and everyone knew."  We picked up the paper, rounded up the scraps into balls, and tried to make a basket as we threw them away.  If angry feelings continued at home, I encouraged him to write them in a letter or journal, or talk into his tape recorder.

Young people like Adam sometimes like to use a punching bag to safely express anger.  Adam arrived at grief therapy filled with rage.  He explained his teacher made him sit on the bench all during recess for fighting with another child named Malcolm.   He was sure it was Malcolm's fault and began punching him furiously on the punching bag as he chanted, "I hate your guts."  Then Adam drew a picture of Malcolm's face and taped it to the punching bag, repeating his chant; "I hate your guts!" as he continued.  Adam was able to identify his object of anger and vent in a safe space. He it was safe to work out his anger on a punching bag so that he wouldn't need to with real people by hitting them or himself. We began to brainstorm safe ways to show anger. Adam realized he could punch a pillow at home if he had these feelings or blow up a paper bag and pop it.

Outcome of Adam's Case

A team conference was held at Adam's school to evaluate school performance, behavior, and possible specialized placement to meet Adam's specific needs.  The team consisted of the principal, guidance counselor, teacher, school nurse, psychologist, Adam's mom, and myself.  Each person gave input and the data was explored and noted.  This team decided Adam needed a special placement with small classrooms, ongoing resources, and daily therapy.

Adam's mom was urged to have a professional evaluation to determine if medication or other resources might be needed.  Adam's mom was given several resources to use with Adam at home.  Books such as Don't Pop your Cork on Tuesday (Moser, 1988) offer stress techniques using deep breathing and internal counting that help create inner controls. The series I'm Mad, I'm Sad, I'm Frustrated (Crary, 1992) allows children to relate to these emotions in others and to identify the feelings in themselves. The Interactive storybook and memory book, Children Also Grieve (Goldman, 2005), allowed Adam and his Mom to share feelings about his dad that died.

Adam's mom was given several suggestions on how to allow Adam to directly act out his anger in ways that would not hurt himself or anyone else.  A rigorous sport such as soccer or basketball was offered as useful, as well as simple exercises such as swimming or jumping rope.   Adam could yell outside or in the shower.

Although counseling services were to be provided with this new placement, I remained in contact with Adam and his mom.  I also spoke to the team of school personnel working with Adam through a multi-phone system several times. His emerging rage and accompanying withdrawal demanded ongoing daily services that could meet his needs.  The school services provided Adam with daily counseling, small classroom size, and a multitude of academic and therapeutic resources. After six months into this program, Adam's mom reported he had been chosen as the "Student of the Month" in his classroom. His outbursts of rage had decreased, and he was more communicative with teachers and classmates.

Recommendations for Grief Counseling

Signs of complicated grief signal multi-level therapy and adjunct interventions may be necessary.  In Adam's case, the following signs were present:

Adam's signs

  • Outbursts of agressiveness and rage
  • Extreme feelings of unworthiness and despair
  • Nightmares and bedwetting
  • Conflicted relationship with father
  • Poor grades and inability to concentrate

His history of previous multiple losses and the sudden and traumatic death of his father are significant related factors.

Memory work: Memory work is an essential tool when working with children like Adam with grief work.  This may include work with photographs, treasured objects, drawing and writing in memory books, or tape recordings and videos.

These techniques help children like Adam who have suffered the sudden loss of a loved one confront a stigma such as that associated with homicide. Adam's low self-esteem reflects the need for creative avenues to release past memories and feeling causing him present pain.

Memory books are participatory workbooks that enable children to draw and write their feelings and thoughts in an interactive way.  They can be purchased commercially (Goldman, Children Also Grieve, 2005) or made to specifically meet the needs of the child.  The following are helpful examples for children:

  • Draw how you found out your loved one died.
  • Draw the funeral.
  • If you could see your loved one more time, what would you say?  What would they say to you?
  • If you could change one thing or do one thing over, what would it be? (This helps to bring out any guilty feelings.)
  • Draw what your family was like before your loved one died.  Draw what your family is like now.
  • What is your funniest memory of your loved one?
  • Write a letter to your loved one.  Tell him or her how you feel about their death? (If suicide or homicide be specific)
  • List or draw what you worry about since your loved one died.

(Adapted from Goldman, Life and Loss, 2nd ed. 2001)

We can help children create memory boxes or a memory table to provide places to store treasured items of a loved one.  Memory boxes can be made from a shoebox that s painted and decorated to house precious belongings.  A special table can be displayed in the child's room, a classroom, or grief support group with pictures and other objects that are meaningful to the child.  Children can bring a picture or special object they would like to share and place it at the table.

Photographs, videos, and tape recordings are concrete ways to stimulate visual and auditory memories of a loved one. Making a photo album of pictures children choose and having it titled "My Life" brings in a clear picture of times and an event shared as well as serves as a motivation for discussion.  So often kids feel they might forget how their loved one looked and sounded.  These are tangible ways to facilitate memory work.

Projective Techniques: Storytelling, drawing, clay, and toys are good examples of projective techniques.  They help represent people and events and were used to afford Adam a vehicle to safely project scary feelings.  Children are often unable or unwilling to verbalize feelings directly.  They may be terrified of telling a family secret or have had no role models to show feeling vocabulary.  Projective techniques can unlock the door to hidden feelings and release a frozen state if being.

Professional Help:  Signs of complex issues can become a red flag to explore a professional evaluation, therapy, or a school team conference that includes all school personnel who work with a grieving child.  This school team can evaluate behavior and school performances, do appropriate school testing, and make a decision about the most appropriate ways to work with the grieving child. In some case, a school placement or school pupil personnel worker home visit may be helpful.

Summary

Adam had begun the meltdown process by allowing himself to feel his rage at his dad, by identifying and separating his feelings through projective techniques and memory work, and by expressing these feelings outside of himself.  Adam is a poignant example of complicated grief, all too common in today's world.

Many categories of complicated grief are a part of Adam's history. They include a sudden or traumatic death (murder of dad), social stigma of death (homicide), multiple losses (dad left as infant, dad's death, mother's illness, multiple residences), and conflicted relationship with the deceased.

Adam's new academic environment provides immediate and daily services for a child with these multi-faceted, complex grief issues.  Grief therapy served as a bridge to help discover, recognize, and treat the severe underlying problems that needed to be acknowledged and addressed in a case like Adam's, and to search out and establish the best possible environment to promote healing.

 

References

Crary. E.  (1992).  I'm Mad, I'm Sad, I'm Frustrated. Omaha, NE: Centering Corporation.

Fox. S.  (1988). Good Grief: Helping Groups of Children When A Friend Dies, Boston, MA: New England Association For the Education of Young Children.

Goldman, L.  (2002). Breaking The Silence: A Guide to Help Children With Complicated Grief, 2nd Ed. Taylor and Francis.

Goldman, L.  (2001). Life and Loss:  A Guide To Help Grieving Children, 2nd Ed.  Taylor and Francis.

Goldman, L.  (2005). Children Also Grieve: Talking about Death and Healing. Jessica Kingsley.

Moser, A.  (1988). Don’t Pop Your Cork on Tuesday.  Kansas City, MO:  Landmark Editions.

 

© Adapted from the article The Meltdown Process in Children's Complicated Grief: A Case Study. ADEC Forum 1996 with permission.

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