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Why some bereavements are more difficult for children and young people, and what can help
Research Practice Focus #1 | September 2020
In this Research Practice Focus video, we explain what research says about why children and young people sometimes struggle to adapt to bereavements; and consider the implications for practice.
Watch the video
About the speaker
David Trickey
David Trickey is a Consultant Clinical Psychologist who has specialised in working with traumatised and bereaved children, young people, and families for more than 20 years. He continues to focus on direct clinical work, as well as the training and supervision of other practitioners. He routinely acts as an expert witness in civil and criminal cases and in 2018 was part of the NICE committee to revise guidelines on PTSD.
Notes on the research
Research links from the video:
- Fauth, B., Thompson, M., & Penny, A. (2009). Associations between childhood bereavement and children’s background, experiences and outcomes. London: National Children’s Bureau.
- Siddaway, A. P., Wood, A. M., Schulz, J., & Trickey, D. (2015). Evaluation of the CHUMS Child Bereavement Group: A pilot study examining statistical and clinical change. Death Studies, 39(2), 99-110.
- Sandler, I. N., Ayers, T. S., Wolchik, S. A., Tein, J. Y., Kwok, O. M., Haine, R. A., … & Weyer, J. L. (2003). The family bereavement program: efficacy evaluation of a theory-based prevention program for parentally bereaved children and adolescents. Journal of Consulting and Clinical Psychology, 71(3), 587.
- Trickey, D., & Nugus, D. (2011). Evaluation of a therapeutic residential intervention for traumatically bereaved children and young people. Bereavement Care, 30(1), 29-36.
- Rosner, R., Kruse, J., & Hagl, M. (2010). A meta-analysis of interventions for bereaved children and adolescents. Death studies, 34(2), 99-136.
Video Transcript
My name is David Trickey, I am a consultant clinical psychologist at the Anna Freud Centre, and co-director of the UK Trauma Council. I have specialised in working with traumatised and traumatically bereaved children, young people and their families for more than 20 years.
Bereavement
Most people will be bereaved at some point during their life. For example, one study found that from a representative sample of children and young people aged 5-16 from around Great Britain, 10% had experienced a bereavement of a friend or a parent . Now of course the grief that follows a bereavement can be an extremely difficult and painful process. But it’s important to remember that many children and young people can be supported through their grief and helped to adjust to their loss.
Research seems to show that, broadly speaking, many forms of support and intervention offered to bereaved children and young people are largely effective; leading to reduced distress and improved ability to cope . This is true even when you compare the impact of an intervention to a control condition or when the deaths are clearly traumatic such as murder and manslaughter , And this effectiveness is demonstrated even if you take a number of different trials and combine them in a meta-analysis (which is just a fancy way of taking an average of all of the studies).
Taking a detailed look at what these effective interventions and support programmes contain, can help us understand what can be so difficult about bereavement – what are the obstacles to adjustment that some children and young people face that interferes with or derails their grieving process. And then of course this understanding can help us to provide the most effective support and interventions.
So, let’s consider six different facets that are commonly included in effective interventions:
- Saying goodbye
- Social support
- Having permission to express emotions – whatever they may be
- Meaning making (or making sense of events)
- Developing what is known as a continuing bond with the person that died and
- Processing the traumatic nature of the death
Saying goodbye
The opportunity to say goodbye in some way, seems to be really helpful. It might not make the death any less sad, but it often seems to help the bereaved person’s subsequent adjustment to the loss. But in some situations, children and young people may not have had an opportunity to say goodbye. The death might have been sudden and unexpected; children and young people may not have been able to visit the person in hospital as they were dying, perhaps because of restrictions in place to reduce the risk of spreading an infection such as coronavirus. The body of the person that died might not be available for viewing, which may deny the bereaved friends and family that opportunity to say goodbye. They may not be able to attend a funeral or other ceremony, perhaps because of social distancing restrictions, or perhaps because an adult decided that the child shouldn’t attend.
Children and young people may really benefit, even some time after the death, from having an opportunity to explicitly and possibly symbolically say goodbye. How can a child or young person be helped to say their goodbye? Perhaps they could write a letter to the person, or there could be a ceremony of some sort, even a long time after the death in which people gather together to say goodbye in a supportive way.
Social support
Bereaved children and young people can sometimes feel very alone. Sometimes following particularly shocking deaths, the child or young person’s usual support system might not feel able to help them, and so they stay away. For example a neighbour may know what to say if an elderly relative dies peacefully in their sleep. But if a parent has taken their own life, then that same neighbour may be so afraid of saying the wrong thing, that they say nothing and actively avoid the family.
The child or young person may even deliberately isolate themselves, perhaps because they don’t think that anyone else can possibly understand what they are going through. So just at the moment when they could really benefit from their familiar social support, they find themselves very isolated and very alone. Sometimes that social support is helpful because the bereaved child or young person wants to talk about what they’ve been through with someone that they already know and trust; and sometimes it’s helpful because the child or young person wants to just carry on doing whatever they used to do – they want to hold on to the idea that some things about their life have remained the same despite their bereavement.
So, those around the child or young person may need to make a special effort to ensure that they feel supported by family AND friends. So, they may need a bit of encouragement or help to maintain their existing friendships. Many bereavement services run groups for children and young people, and many of those children and young people find it so comforting to be with people of their age, who are going through something similar.
Having permission to express emotions – whatever they may be
Most effective interventions or support include the opportunity to discuss, explore, express and process emotions – whatever those emotions may be. It might be acceptable within a family or friendship group to be sad after someone dies. But what if the child or young person feels really really angry? What if they feel really really angry with a specific person whom they see as being responsible for the death? Are the people around the child or young person able to allow them to have, and express those feelings; or do they close them down in some way, so that the child or young person ends up having to deal with them on their own? What if a child or young person isn’t as sad as everyone else seems to be – is that ok as well?
What if they are really really scared because of the death? Do they have the chance to express that and discuss it openly? And what if the initial death was such a shock, so hard to really take it in, that it takes several months before the child or young person starts to experience any feelings – are those around them able to realise that the feelings are linked to the death?
And what if the child or young person doesn’t really have strong overwhelming feelings about the death – are the adults around them able to tolerate that too?
If these strong and confusing emotions are part of the problem, then those around the child or young person may have to invest time to get alongside them, be curious, and ask in a very open minded way how they are doing and how they are feeling, allowing them to have those feelings – and resisting the temptation to try to change them too quickly. It might be really helpful to find less direct ways to help children and young people to express these feelings, perhaps through art or play.
Meaning making
What does the death mean for the child or young person? What is the meaning that they attribute to it? For some children and young people, the death has far-reaching and long-lasting implications for their views of the world in general, other people and themselves. The death may shatter their understanding of how things are ‘supposed’ to be.
It might be that the ‘catastrophic’ message of the death overrides all their previous experiences, so they develop a new view of the world, other people and themselves, that is very negatively tinted by the death.
For example, if the death was due to an act of violence, then the child or young person might start to believe that all other people are dangerous, and that you cannot trust anyone. If the death was due to a disease and happened very suddenly and unexpectedly, the child or young person may start to think of everyone as being incredibly vulnerable and the message could be anyone could die at any moment. As a result of these beliefs children and young people may be very reluctant to invest energy in any relationships – old or new.
A child or young person may be so scared because of their understanding of the way that the person died, that they find it impossible to be sad about their loss.
Children are particularly prone to feeling responsible and guilty – they may not have been given enough information about how the person died, and in their search for meaning and a plausible explanation, the child or young person might create their own explanation, in which they are to blame in some way for the death. So, thinking that it’s their fault may actually make sense to them.
For example if a child or young person is told that if you wash your hands properly then a virus will not affect your family, if someone in the family subsequently dies of that virus, the child or young person might think that it is their fault because they did not wash their hands enough.
There may be different accounts from different sources of how the person died e.g. different members of the family, or news media or social media, and this may substantially add to the confusion.
This meaning-making relies on having accurate and appropriate information about how and why the person died. And, accurate, culturally appropriate information about what happens after death. This vital information is sometimes not provided to the children and young people because those around them want to try to protect them from distress. For example, if a child is told that the person that died is now on the moon, then the child may wonder if they took their own life, would they go and join them.
So, it’s really important that those around the child or young person are able to support them in making sense of the death which is accurate and balanced. And this might involve some difficult conversations about how the person died. It might involve allowing the child or young person to ask whatever questions they may have, and then providing them with honest and helpful answers, in an age appropriate way.
Sometimes as children get older they need increasing amounts of information and detail. So the trick here is to provide them with an account of the death, that you can ADD information to, not one that you have to replace with wholly new one. It’s a bit like a dot-to-pot picture – for young children you might start with just the dots, then as they get older you start to join some of the dots up, then as they get older still you start to colour it in.
Developing a continuing bond
Some adults are keen to avoid speaking with children and young people about the person that died; they may worry that this will upset them unnecessarily. But many children and young people adjust better to their loss by developing a continuing bond with the person that has died. Of course, this bond or relationship will be different to the relationship that they had when the person was alive, but the person that died can still remain a part of the child or young person’s life. Children and young people might want to be able to speak about the person that died, to remember what they were like, to recount stories about them – even if this seems to make them upset. This is one way that a child or young person can be helped to hold on to precious memories about the person that died, which can help them to as they move forwards.
Processing the traumatic nature of the death
If the nature of the death was ‘traumatic’ in some way, then the child or young person might be too preoccupied with the way that the person died, to be able to remember the way that that person lived. And this can halt their grieving.
And it’s important to say here, in order to decide whether a death is ‘traumatic’ or not, we don’t make some objective assessment, it’s not for US to decide. What we do is we listen very really carefully to the child or young person to see what they make of it.
If they do consider the death to have been traumatic, then the child or young person may have some really difficult, sharp and scary memories or images of the death that take precedence over their softer more comforting memories of the person’s life.
In such cases, the child or young person may need help to ‘process’ the way that the person died, to talk it through or play it through or draw it through, so that they are able to put those memories and images behind them and focus on their memories of the person that they choose to bring to mind.
Summary
So, in summary, based on what the research indicates seems to be effective types of intervention or support, there are various things that are likely to help children and young people to adjust when someone they know or love dies.
After some deaths, some of those helpful things are missing or compromised, and this can really impede the child or young person’s grieving process.
Taking a detailed look at what these effective interventions and support programmes contain, can help us understand what can be so difficult about bereavement – what are the obstacles to adjustment that some children and young people face that interferes with or derails their grieving process. So we need to take the time to listen carefully to these children and young people and try to really understand what is going on for them. And then we can work out what can be done to support them through their grief and reduce the negative impact of the death.