Counselling for kids

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The traditional attitude that says we should hide death from toddlers causes life-long emotional problems, says Liz Koole. She reports on her counselling group for bereaved preschoolers and their parents.

Bowlby’s theories of attachment are well known and a secure attachment to a caregiver is thought to provide a base for a child to safely explore the world around them and find their place in it. Extended loss or separation, such as the death of the main caregiver, can lead to behavioural, emotional and mental health problems. There is a need to pay particular attention to bereaved children under five years old because there is “uncertainty, ambiguity and inconsistency” (Bowlby 1980 p274) in societies surrounding beliefs of life and death - which can add further confusion when a child’s cognitive abilities are limited.

Research suggests early childhood experiences are very important in influencing children’s “emotional health, resilience and social competence” (David et al 2003). There has been much research into the long-term effects of early parent death. Some studies have suggested an association between early parent death and adult depression, manic depression, alcoholism and schizophrenia (Finkelstein 1988). Van Eerdewegh et al (1985) found that children bereaved before the age of four years three months were more likely to be referred for psychiatric care five or more years later.

Social support after bereavement can affect children’s outcomes. Ruiz-King (2000) suggests that if children are supported through the natural processes of grief they are capable of: “Turning grief into growth and pain into gain”. Research done by Christ (2000) shows that bereavement playgroups are of great benefit to preschool children.

Understanding young children and grief

Not knowing what to say to their children, or fearful of causing avoidable distress, many parents fail to give their young children sufficient information for them to process the fact that someone has died, and what this means. The consequence of this is that children are either left with a big gap in their knowledge and strong emotions they cannot connect to anything - or they make up a story that makes sense of the facts they do know, and become very confused.

Our understanding of children who have been bereaved very young is that their knowledge of what has happened grows with them throughout their childhood, developing in maturity and complexity. But in order to be able to do this, they need to have certain building blocks to which other information can be added. These building blocks are honest facts about what caused the person to die and what it means to be dead. The children need to realise that their feelings associated with the loss are perfectly normal - and that it is okay to talk about the person who died. As children develop cognitively and feel able to ask questions, they become interested in practical facts associated with road accidents, or how you die from cancer. Later, they come to realise the implications of the death for themselves and others.

A young child told that their parent took their own life accepts this quite factually and grows up with that knowledge, as if they have always known it. Only if this is the case can they later ask questions and be given more information as they get older. By the time the child is old enough to think about the meaning of suicide, they have already become familiar with the words and the idea - so they grow into an understanding of it.

At Winston’s Wish, the charity for bereaved children, we think of it like a jigsaw. When a child is three they may do a jigsaw that has six pieces. When they are nine they need to do a jigsaw that has 100 pieces, even though it is of the same picture. By the time they are 16, their jigsaw may need 2000 pieces in order to have the necessary detail. So their gradual understanding of what death means grows naturally alongside their age. Rather than worrying about getting it right or wrong, a parent needs to think about allowing and supporting their child to revisit their grief throughout their childhood. This can seem quite daunting - and at the same time quite liberating.

The Group

We started a counselling group at Winston’s Wish for preschoolers. Our first counselling groups were offered to children five years and under who were siblings of children who had attended one of our residential weekends (Stokes 2004), or who had been referred to us but were too young to attend a weekend. The groups run on a weekly basis for six weeks and reflect the residential weekends in that they are an intervention for both children and their parent(s). This demands commitment from the parents and a recognition that parents are part of the solution for their children. (The group is available for the child’s parent or appropriate carer, but for the purposes of this article, the word ‘parent’ will be used).

Assessment

Children are assessed for the group with their parent(s) along the lines of our usual family assessment (Stokes 2004), which models openness, information sharing, giving the child a voice, acknowledging the death of the important person, inviting the family to tell the story of how that person died and to share memories of them. This needs to be done in a very simple and short form for young children because of their developmental levels of understanding and limited concentration span. It is important to show that it is alright to talk about what has happened and to have strong feelings. The children should also be told that it is alright to ask questions and to be curious - what they say and think matters.

During the assessment, we hold in mind certain criteria that are important in order for the group to function. We then undertake meaningful activities – children need to be able to separate from their parent, be part of a group, take turns, listen to others and participate in activities with support. Both parent and child are given information about the group and the content of the sessions, and agreement is sought from both about attending.

The Sessions

The six sessions consist of:

  1. Beginnings and introductions
  2. Families and how people die
  3.  Alive and dead - the differences
  4. Feelings
  5. Funerals – what happens after someone dies?
  6. Endings and goodbyes
     
    Over the years, these sessions have been refined and evaluated as we have understood better how young children understand and think about death. We have learned how children discover the world around them and how they express themselves. This has led us to incorporate their developmental stages into each activity and use ways in which they operate in their day-to-day lives - primarily through play and exploration.

Each session, we all recognise that we are part of the group. We acknowledge any good or difficult things that have happened in the week and ask how people are feeling. We have a game together to have fun and help families relax and interact with each other. 

Based on the short concentration span of young children and the importance of play as a means of learning, the sessions are divided into a formal lesson followed by a time of play or creativity based on the theme of the day. This is separated by a break - for a snack, a drink, chat and relaxation.

Each session produces something tangible for the children to put in their memory boxes as a reminder of what they have done. The session ends as it began - with everybody together. The purpose of this is for parents and children to share what they have done and how this has made them feel - our aim being to model open communication to take home.

The parent’s sessions mirror those of the children. They give opportunities for parents to express their grief, but also be introduced to the activities their children do. In doing this, they are able to think about the parts of their story they find hardest to talk about with their children and the responses they are afraid of, both in their children and themselves.

The parent’s group considers how to deal with these issues and shares useful activities and books. Parents are often anxious about the content of the sessions- but in addressing their own needs and anxieties and giving starting points and tools for difficult conversations, parents grow in confidence and develop their skills in talking with their child in the days between sessions. At the same time, their children are growing in their understanding of death and their own family story. They are also developing an emotional literacy and ways of expressing themselves and an understanding of their parent’s feelings that makes the parent’s job easier.

Session one

Young children are the centre of their own universe, so in this session we get them thinking about themselves, using mirrors, before going on to think about their family and the person who died.

Adults talk about remembering, but this is a difficult concept for young children. So in the form of a game, we introduce the idea of remembering before we ask the children about the person they have come to remember. Children bring a photo of themselves with the person who died, as this expresses a relationship. The photo prompts a discussion about what they were doing at the time.

We discuss different ways of remembering someone, with the help of a story book, and the session ends with the introduction of memory boxes and lots of feathers, sequins, material and stickers to decorate them.

Session two

Children need to think about who is in their family before they can start to work out where the person who died fits in. What is their relationship to the rest of the family now that they have died? Building up a clear picture of how someone died helps to avoid fantasy and guilt - both very strong at this age of magical thinking.

We use storytelling as a theme that children will understand, and role modelling to show how they can think about what happened in their family as a story. This is based on narrative therapy  - people can generate and evolve new narratives and stories to make sense of their experiences. “In doing this we draw on culturally shared narratives or ways of interpreting events and also our own family traditions” (Dallos and Draper 2005 p 107).

Practitioners act out a general story where someone dies, using toy figures. This sparks a conversation about the child’s family and the person who is not there anymore. The concept of being part of the family, yet not being physically present, is tackled by the children by choosing pictures of their house and pictures of their family, which they stick in or around their house. The person who has died is placed in a thought bubble. This shows that although they don’t live in the house any more, the person is still in people’s thoughts.

After the break, practitioners help each child prepare three short cameos to help them tell their story of what happened before, at the time and after the person died, using puppets. They are then helped to act these out to the group. These skits are very short and simple - but they help the child to take ownership of their story and to share it with others. It gives us insight into how they understand their story.

The power of using children’s own way of expressing things was demonstrated very clearly by a four-year-old girl. During the assessment she talked very factually and precisely about her twin sister’s death. Yet, when acting it out, she showed a real connection with what had happened in the sudden strength of her emotions and what she did with the figures.

Session three

In session three, we used an episode from a children’s cartoon which discusses key feelings surrounding the death of a pet bug – disbelief, immobility, separation, conflicting emotions, grief, remembering and saying goodbye. Television is a medium children get lots of information from, but many cartoons show death in an exaggerated or unrealistic form, with heroes getting up to fight another day after dying.

This provides a stimulus for thinking about the differences between being dead and alive. To help with this, we gathered a selection of things that are dead and alive - woodlice, bees, spiders, starfish, dead leaves and living leaves. We even have a little animal skeleton and a visit from a lively dog. The interest sparked by these things leads naturally into discussing how you can tell if someone is dead or alive and what causes things to die. Children’s natural curiosity causes them to ask all kinds of questions which parent’s dread. Knowing that their children have talked about these things can be quite a relief for parents.

Session four

Feelings are another abstract concept that needs to be adapted to a child’s level of understanding. Our experience is that very young children find it hard to identify and name feelings in themselves or others.

So before talking about how people feel after someone dies, the children need to get used to the idea of expressing and recognising feelings. To do this, we play a ‘guess the feeling’ game. The idea behind this is for the children to think about situations that provoke emotions, how people express feelings in their behaviour or actions and how to recognise how someone else is feeling. This is a difficult task for young children and we haven’t got it right yet. But it helps for children to begin to recognise how their parents might be feeling, and how to express their own feelings to people around them. Using bubbles helps the children understand in a fun and accessible way that feelings can have different intensities and last for different lengths of time.
 
In this session, practitioners also act out stories with puppets to demonstrate a variety of feelings in situations the children can relate to. This is very much enjoyed by the children. The puppets are put out later for free-play time.

Session five

Session five is about what happens after someone has died. Basic facts to an adult - but a whole mysterious world if you are under five. A lot of this topic is about unpicking words that adults use around a bereaved child. A young child may learn to use the words ‘funeral’, ’coffin’, ‘cremation’ and ‘burial’ - but she does not understand them unless they are explained.

The purpose of the session is to teach the children about the rituals associated with death. This is all part of the child’s narrative - what happened around the death, how loved ones said goodbye, whether the body was buried or cremated and why we visit a ‘grave’. It also allows the child to place themselves in this narrative by acknowledging their part in, or absence from, these events.

We have discovered that children learn this new vocabulary best by exploring it for themselves - alongside honest information, hands-on experience and serious play. Children are invited to look at a toy coffin and a doll that can be put in it. Choosing how far to participate also helps children to be in control of things when they have probably had little control over anything else related to the death.

Building on the cartoon, we give the children a dead bug so they can play act a funeral. This may start with a reminder as to how we know the bug is dead, and leads on to deciding what to do with it and how to say goodbye. A little box is provided that the children are invited to decorate with a little headstone. They decide what to write on it. All this enables conversations about why these events take place and how families make decisions.

The children choose flowers to take to the grave, then children and practitioners go to the garden and bury the box with the bug in. This is a very lively session, with lots of talking and competition for who will carry the box and dig the hole. Flowers are laid, plants are planted, the headstone is put up and the children spend a few moments quietly thinking about the bug.
By acting out this funeral, we hope the children will understand what is meant when the word is used at home, whether or not they attended themselves. We have found that children spontaneously relate what they are doing to their own family death: ”I didn’t go to the church”, “My daddy’s got a picture on his grave”. Children also talk about visiting the grave and a connection with this is made in the last session, when we revisit the grave to take fresh flowers.

In our evaluation of the group, parent’s rated this session on funerals and the session on the differences between ‘dead and alive’ as the most useful - as they teach the children about the things their parents find most difficult to talk about. After the sessions, parents note a significant improvement in their ability to talk with their children about these issues without getting upset or feeling inadequate.

Alongside burial, we have had to face the dilemma of what to tell children about cremation - as many of the parents who died were cremated. Based on the idea that children at this age are very factual, we decided to present it very factually - anticipating that the difficulty belongs to the adults who have to explain it and not the children who hear it. 

Children do indeed accept cremation factually and, maybe to our initial discomfort, often want to put their fingers into the ashes and feel them in the little pot we have for another bug who has been cremated.

At Winston’s Wish, we live constantly with the question of how much is it appropriate for children to k now. Is knowing something difficult ever detrimental to children’s wellbeing? Certainly, when explaining burial or cremation, a clear understanding of what it means to be dead is important so that a child is not left with disturbing issues. The group sessions are carefully sequenced to build on each other - and parents are told of the importance of attending all the sessions because of this.

After the burial, we return to the room to light a candle as a way of introducing the children to a way of remembering someone. The children say who they are remembering, and the candle is lit for all of them. This activity is repeated with the parents in the end session to show them what we have done, talk about how they might use it as a family and to give candles to the parents to take home.

Session six

Session six starts with a visit to the bug’s grave with fresh flowers. The rest of the time is used to remind the children of the content of each session, using the objects in the decorated memory boxes to remember. These reminders are also shown to parents at the end of the session, with the help of the children, so that the box and its contents can be the focus of useful, ongoing conversations at home. Each parent also shares one thing they have learned from their child over the six weeks. The aim is to encourage openness around talking about the death and recognition that it affects both children and parents.

In any groups related to the experience of bereavement, goodbyes are very important. Families are reminded at the beginning that this is the last session - and time is spent at the end helping parents and their children relate to each other.

Before leaving, children are given a soft toy to remind them of the group and parents are given a copy of one of the books used to read with their child and a list of all the books read over the course of the group. This is a sign that they now have the tools to continue what we have started. Families are told about the follow up session, which is held six weeks later, and are encouraged to keep in touch with each other as a means of mutual support.

Follow up

The children have worked hard during the course of the group, so for them the follow up is purely about having lots of physical fun in the company of the same group of people. For parents, the follow up session is a time to compare notes, share concerns arising from the group and reflect with practitioners how they can put the teachings of the group into day-to-day practice.

Evaluation

Before attending, parents are asked to complete a form expressing their hopes and expectations for the group. Some parents worry that attending the group will stir up difficult behaviour in their children.

An evaluation form is completed at the end of the last session, and another at follow-up. This is to gather immediate responses, then more reflected thoughts, on the group-process and any changes they saw in themselves or their child.

Parents report that:

  • although there are still tricky moments, generally their children’s behaviour improved.
  • for some children, sleeping and bedtime routines improved over the course of the group.
  • the group helped their children, and often themselves, to talk more openly about the person who died to family members and others.
  • they discovered that they also have a right to grieve and that this can be combined with being a ‘good enough’ parent.
  • they felt better prepared to deal with questions and more confident about handling their children’s grief after attending the group,
  • they felt their children had grown in confidence and resilience.

From ongoing contact with these families over a number of years and reports from teachers, it seems that children who attend the group are often more emotionally mature and literate than others their age.

“Children’s reactions depend to a great degree on the way we, as adults, are able to respond, and the foundation we give them for processing their feelings and reactions. By letting children take part in rituals for grief, by keeping communication channels open and truthful, and by talking with children about what has happened, the best basis is laid for them to process their feelings and reactions” (Dyregov 2008 p85).

Liz Koole is a senior practitioner at Winston’s Wish, a charity for bereaved children. The charity provides counselling before, during and after a bereavement and operates a helpline.

Taken from Every Child Matters

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References

 

Bowlby, J. (1980) Attachment and Loss: Vol 3 Loss, Sadness and Depression. London Hogarth Press.

Christ, G. H. (2000) Healing Children’s Grief: Surviving a Parent’s Death from Cancer. Oxford University Press.

Dallos, R. and Draper, R. (2005) An Introduction to Family Therapy: Systemic Theory and Practice. Open University Press

David, T., Goouch, K., Powell, S. and Abbott, L. (2003) Birth to Three Matters:A Review of the Literature. DfEs Publications (dfes.gov.uk/research/)

Dyregrov, A. (2008) Grief in Young Children: A handbook for Adults. Jessica Kingsley Publishers

Finkelstein, H. (1988) The Long Term Effects of Early Parent Death: A Review. Journal of Clinical Psychology, Jan, Vol 44, 1.

Hogwood, J. (2003) Rationale – Is There a Need for a Pre-school Intervention Programme?

Ruiz-King, C. (2000) Bereavement in Children: A Group Proposal.

Stokes, J. (2004) Then, Now and Always. Portfolio Publishing.

Van Eerdewegh, M., M., Clayton, P., J. and Van Eerdewegh, P. (1985) The Bereaved Child: Variables Influencing Early Psychopathology. British Journal of Psychiatry 147, pp 188-194.

 

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