By Beth Patterson, MA, LPC

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In my work with grieving children and adolescents, it is important for me to keep in mind that the child’s age and stage of development at the time of the loved one’s death will strongly influence the ways in which the child reacts and adapts to the loss. “Besides cognitive understanding, a child’s degree of separation-individuation, along with the developmental maturity of the child’s ego defenses and ego functions, will influence his or her psychological reactions to bereavement” (Baker & Sedney, 1996, p. 115). Cognitive development is also of paramount importance (Worden, 1996, p.10). Thus, an understanding of the child’s emotional and cognitive development will enable me to determine how best to communicate about death with the particular child, to understand and empathize with the child’s experience and guide the child through the grieving and healing process with appropriate interventions. It is also important for me to be aware of my own triggers around death and loss in order to stay present with the child’s process and deal with the death directly, since shielding children from death deprives them of the ability to grieve and ultimately heal.

This paper will examine assessment and interventions with a grieving twelve-year old girl, who I will call “Abby.” I have worked with Abby both individually and in a small group with other grieving pre-teens at a hospice-based children’s grief support group. Abby’s maternal grandfather died suddenly and violently two years ago while cleaning his gun. There is some uncertainty as to whether the death was accidental or a suicide.

Abby is an only child, who lives with her mother. Although Abby has not spoken with me about it, her mother has reported that Abby’s father physically abused Abby when she was four or five years old and he has been court ordered to not have contact with her. Abby has not seen her father (who is divorced from her mother) since she was six years old. She had a very close relationship with her grandfather, and spent every Saturday with him, doing special things together. Abby reports that since her grandfather’s death, she spends her Saturdays alone, mostly sleeping. In addition, although Abby is exceptionally bright and attractive, with many interests and talents, she has had a difficult time making friends at her middle school because of her need for control.

The Interdependence of Grief and Development

Childhood grief and development are interdependent: The early death of a parent or other loved one affects a child’s development, and the child’s development affects how he or she will grieve and reconstruct his or her relationship with the deceased. Furthermore, children re-experience their grief as they reach each milestone in their development. Most children retain a “psychological relationship” to the deceased, and the child renegotiates that relationship at each stage of development (Christ, 2000, p.13). Garber (1988) calls this process construction and reconstruction: The deceased loved one is a “missing piece” (quoting the poem by Shel Silverstein) that the child needs to reconstruct in order to provide himself with a “history of his past that he could then build on, alter and modify with changing developmental concerns….During each succeeding developmental stage, he may need to step back and…reconstitute the missing piece” (Garber, 1988, p. 272).

Capacity to Grieve and Understand Death’s Finality

A child’s ability to understand the meaning and finality of death corresponds to his or her cognitive development. For example, a three to five year old, in the preoperational stage, believes that the deceased person has gone away and will return at some point. Thus, it is common for a child of this age to constantly ask questions such as “Where’s Daddy?” and “When is Mommy coming home?” A child of five to approximately nine years of age, in the concrete operational stage of cognitive development believes that death can be avoided. Furthermore, a child in this egocentric phase also believes that his or her parent died because either the parent was bad or the child was bad, and that if the child is good, the parent can return. This is thus seen as one of the most vulnerable and difficult developmental stages for adjusting to a parent’s death (Christ, 2000, p. 18; Fogarty, 2000, p. 25).

In working with Abby’s grief over her grandfather’s death, I always need to keep in mind that she is dealing with her loss both from her newly acquired formal operational cognition, and from the pre-operational and early concrete operational stage she was in when her father abused and then left her. Thus, she may be relating to her grandfather’s death emotionally from that earlier stage, and may believe that she is somehow be responsible for his death. Christ (2000, p. 108) suggests that the child at this stage “needs someone who can clarify what the child is thinking and feeling, can reframe events to make them more understandable, can reassure and build self-esteem by praising the child’s accomplishments and by emphasizing the child’s importance.” This is something that I try to do each time I meet with Abby. As Fogarty (2000, p.25) notes, It is vital for grief therapists, caregivers and parents to have full knowledge of how children’s cognitive development affects [their] ability to mourn… Children have developing, and therefore incomplete cognitive equipment, which can create a greater potential for them to accept destructive magical thoughts resulting in a process of complicated mourning.

Abby has moved from concrete operational to early formal operational thinking, and is able to grasp and verbalize abstract concepts about death. Nonetheless, her grief process is still informed by early developmental issues of safety and trust, as well as the magical thinking of the concrete operational stage. One manifestation of Abby’s grief and loss process is that she does not show much empathy for the others in the group, despite the fact that they have all experienced the loss of a loved one, and are all around the same age. Abby’s grandfather’s sudden and violent death, coupled with her father’s abuse and abandonment, seems to have made it unsafe for Abby to trust and truly connect with her peers at a life stage when peers and feeling accepted are so important to social and emotional development. Abby’s grief has thrown her back to the earliest Eriksonian stage of trust vs. mistrust Thus, her work now is about making contact, in the context of mourning.

Developmentally, even in more “normal” circumstances, 12-year olds yearn to belong, but may feel different and isolated, as the brain and body go through a dramatic growth spurt instigated by a surge of hormones. Physically, a 12 year old girl is starting to become a woman, and may experience self-consciousness and awkwardness that may lead to withdrawal. Emotionally, she may experience a strange and seemingly uncontrollable roller coaster of highs and lows exacerbated by pubertal hormonal changes, as well as grief over the impending loss of her childhood. Cognitively, in moving from concrete to formal operational thought, an introspective and intelligent 12-year old like Abby is increasingly aware that others may not share her feelings, thoughts and values. A grieving pre-teen, like Abby, may also feel different because so few of her peers have experienced the loss of a loved one. This recognition can lead to the first taste of existential alienation, causing further withdrawal. Those who are more firmly in the formal operational stage of abstract reasoning can have a more panoramic view about these differences, and develop true compassion and empathy for others. The child not quite out of concrete operational thought, especially one dealing with profound grief like Abby, may have a difficult time getting to that stage, and may regress to more egocentric behaviors, like those I have witnessed in Abby’s case.

A group intervention that I have used for working with Abby’s lack of empathy and isolation is the “Mirror, Mirror” activity described in Playing Along (Gesell, 1997, pp. 24-26). In this activity, each participant is paired with a partner. One member of each pair initiates movements, fully using her body, when the facilitator gives the signal to begin the activity. The other partner then mirrors that movement. After one minute, the facilitator asks the partners to switch roles. After a number of switches, both members become leader and mirror at the same time, “[b]ecoming so in tune with your partner that an outside observer would be hard-pressed to know who was leading at any time” (Gesell, 1997, p. 26). After doing this process for several minutes, I led a discussion about which role was easier for each participant, what was difficult about the exercise and what feelings came up. Although the pre-teens were not particularly able to verbalize about their experience, the exercise was a chance for them to get in touch with their bodies and reach out to and communicate with others in a fun, non-threatening way. At the same time, although they did not talk about it, I felt that the activity also was an opportunity for the group participants to see how they do, and do not, make contact with their peers.

Tasks of Children’s Mourning

Worden (1996) has identified four tasks of mourning: (1) accepting the reality of the loss, (2) experiencing the pain and emotional aspects of the loss, (3) adjusting to an environment without the deceased, and (4) relocating the dead person in one’s life. The satisfactory completion of these tasks depends on both the child’s stage of development at the time of the death and his or her adaptability and ability to attend to any unfinished tasks at later stages of development.

Accepting the Reality of the Loss

A child can accept the reality of losing a loved one when he or she understands, through the achievement of formal operational thinking, “the nature of abstractions such as finality and irreversibility” (Worden, 1996, p 13, citing Piaget, 1954). Some grasp of such abstractions is possible during the concrete operational stage of cognitive development, and is only fully understood at the formal operational stage. Thus, if a loved one dies before formal operational cognition has been achieved, the child will experience a deeper level of grief when he or she attains that cognitive stage and fully and deeply comprehends the finality and irreversibility of the loss.

This is clearly the case for Abby. Although she is emotionally immature, Abby is quite advanced intellectually and has achieved the early stages of formal operational thinking. Thus, Abby has an understanding of the abstraction of death’s finality. She has been grappling in our sessions with giving spiritual meaning to the finality of death. My job is to empower Abby’s cognitive work by normalizing and validating her process and the private thoughts she has chosen to share with me, while at the same time providing a safe space for her emotional process.

Attainment of formal operational cognition, generally in early adolescence, is a particularly vulnerable time in the process of adjusting to a death. Christ (2000, pp. 190-91) calls the adolescent’s profound experience of his or her loss due to the attainment of formal operational thinking, coupled with adolescent developmental tasks such as separating from family, negotiating a more adult relationship with the surviving parent, finding one’s identity and true values and deepening relationships with peers “daunting challenges for adolescents that often exacerbate pre-existing vulnerabilities.” In Abby’s case as a pre-teen on the cusp of these profound developmental challenges, I need to stay aware that as she comes to terms with the meaning of her grandfather’s death, her new cognitive abilities also opens her to a new level of understanding – and pain – about the loss of her father.
Experiencing the Pain and Emotional Aspects of the Loss

The pain and emotions of grief can be frightening for a child to experience. Awareness of the child’s capacity based on his or her stage of emotional development to cope with strong emotions is important. It is also important to assess the child’s coping and defense mechanisms, and their effect on how the child experiences the pain of the loss. The prevalent defense mechanisms for pre-school children are denial and projection, while children in latency tend to intellectualize or split off from their emotions. In contrast, adolescents will most commonly suppress their emotions or sublimate them by an energetic output in another direction, which could be either constructive or destructive. (Baker & Sedney, 1996, pp. 116-17).

In Abby’s case, the abuse and abandonment by her father early in her life has left deep developmental holes and she has split off from her emotions, which has complicated her grieving process over the death of her grandfather. Abby loves to write, and we spend some time in group having her and the others write in their journals. I have also done an exercise with the pre-teen group, where I gave them the beginning of sentences, such as “I miss my loved one most when…” and “My friends…”. The group members complete the sentences in their journals, and then have an opportunity to share what they have written. This has been a useful intervention, allowing the group members to get in touch with their feelings, as well as allowing them to connect with the others and feel less isolated, empowered by the realization that they have all experienced a loss, and they are not so different, after all.

Adjusting to an Environment without the Deceased

This task is an ongoing process through progressive stages of development as well as important transitions throughout one’s lifetime. The child– as well as the adult he or she will become — re-experiences his or her grief at each stage of development as a result of his or her growing cognitive abilities, and also as he or she comprehends the vacuum left by the dead loved one, who is not there to nurture and support the child’s growth and achievements. In addition, the child’s grief will be experienced, and her loss acutely felt, at times of life transitions such as birthdays, graduation, leaving home, marrying and having a child of one’s own. (Worden, 1996, p. 14). Christ (2000, p. 15) calls these transitional events “secondary stressors” that occur as the result of the impact of the death on subsequent events in the child or adult’s life. Abby has experienced some these milestones, such as her birthday and her grandfather’s birthday. An intervention I have used with her is the creation of a memory box for her grandfather, in which she has placed pictorial depictions of their relationship. We also did an art therapy project together when Abby returned from summer vacation. This was primarily a non-verbal exercise in which Abby was able to “tell” her grandfather through the medium of collage about her summer activities and experience her emotions of loss and sadness on a somatic level. My job in this process was to simply sit beside her and be an empathetic witness. In joining with Abby in this way, we have established a good degree of contact and trust.

Relocating the Deceased in One’s Life

As the child grows and changes, his or her relationship with the deceased parent or other loved one also changes (Christ, 2000). Thus, according to Worden (1996), another ongoing task is to find new ways to memorialize the deceased loved one with the attainment of each developmental milestone: Children need to “find a new and appropriate place for the dead in their emotional lives – one that enables them to go on living effectively in the world.” The above-described art therapy projects have been helpful with Abby in this regard. The narrative therapy intervention of letter writing may also be helpful at this stage, having Abby write a letter to her grandfather. This process may help Abby clarify her feelings and create a safe container for them, allowing her to relocate her grandfather and live an effective life.

References

Baker, J.E. & Sedney, M.A. (1966). How bereaved children cope with loss: An overview. In Corr, C. & Corr (Eds.), Handbook of childhood death and bereavement. New York: Springer Publishing Company.
Christ, G.H. (2000).Healing children’s grief: Surviving a parent’s death from cancer. New York: Oxford University Press.
Fogarty, J. (2000). The magical thoughts of grieving children: Treating children with complicated mourning and advice for parents. Amityville, New York: Baywood Publishing Company.
Garber, B. (1966). Construction and reconstruction in a case of parent loss. In Altschul, S. (Ed.) Childhood bereavement and its aftermath. Madison, Ct.: International Universities Press.
Gesell, I. (1997). Playing along: 37 group learning activities. Duluth, MN: Whole Person Associates.
Worden, J.W. (1996). Children and grief: When a parent dies. New York: Guildford Press.

©Copyright 2008 by Beth Patterson, MA. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Beth and/or see her GoodTherapy.org Profile