Factors Influencing Grief

A child’s grief can be influenced by a variety of factors including age, personality, developmental stage, earlier experiences with death, relationship with the deceased, surroundings, cause of death, cultural factors, and family members’ ability to communicate with one another.  Additional factors to consider are the child’s need for ongoing care, the child’s opportunity to share his feelings and memories, the parent’s ability to cope, and the child’s steady relationships with other adults.

Younger children are typically more receptive to the support of family; however when children enter adolescence, they can find it harder to accept help. During this stage, their primary developmental task – separating from their parents and other adult caregivers – is contrary to and can conflict with seeking help from these same people.

Adolescents have a greater propensity to suppress or deny their grief (Abrams 1993; Evans 1996; Henshelwood 1997; Weitz 1989). This can be considered normal for adolescents but may contribute to complicated bereavement.  Adolescents may keep grief and distress private because appearing to be in control is important to them.  Grieving in private precipitates a high risk of isolation, loneliness and feelings of abandonment (Balk 1990). A lack of experience in facing death may result in denial being used as a coping mechanism (Evans 1996).

J. William Worden, Ph.D., ABPP, a Fellow of the American Psychological Association who holds academic appointments at Harvard Medical School and at the Rosemead Graduate School of Psychology in California has found that denial amongst adolescent boys is common because of the social expectation that males should be ‘strong’ and not express emotions, especially in western cultures (1991). This is consistent with findings that adolescent boys felt they had to suppress their emotions in order to prevent further distress to their grieving parent (Weitz 1989; Cragg 1990). Weitz, a grief researcher fromEngland, also found that boys feared losing control of their emotions and appearing different and then being stigmatized by their peers (1989).  As a consequence, adolescents strive to continue with normal activities that may be interpreted by other family members as an uncaring behavior or as a sign of coping successfully with the loss (Hogan 1988).

Social support is of paramount importance for healthy outcomes for teenagers.  Susan Sach, from the Australian Centre of Grief and Bereavement, identified adolescents as one of the two groups of family members who need particular attention and bereavement support when a child dies (the other is grandparents) (Morgan 1991). Most adolescents will turn first to family, whose ability to provide support is often related to each member’s own ability to cope with grief.  If family support is insufficient, teenagers may go outside the immediate family to peers who, unfortunately, may not have the maturity or experience to provide the necessary support.  Evans says it is essential that teenagers be given the opportunity to express their distress and sadness in a safe and supportive environment (Evans 1995).

Factor One: Family Functioning ~

In a review of psychology literature exploring the impact of grief for children, adolescents and teens, unquestionably the most profound factor related to mediating risk of adverse bereavement outcomes is family functioning issues.

Death irrevocably changes the design of a family system. This can be the most challenging, and most painful, time in the life of a family. Roles shift, responsibilities change, and gaps are formed as well as filled. The family system moves into a state of flux and certain behaviors become instituted in an attempt, often with limited emotional resources, to stabilize the system (Bowen 1991).

In a school setting it can be difficult to determine, with certainty, the degree in which families are interacting and coping after a death. However, a basic working knowledge of family typology can provide valuable insight and ultimately help provide the best possible support for a child.

Questions to consider:

    • Does the child have a support system, and if so who comprises it?
    • Are the adults in the child’s life emotionally available to them?
    • Are there stated or unstated rules in the home regarding the death (are all photo’s removed,  can the child talk about the deceased and openly ask questions, was the      child allowed or made to attend the funeral?)
    • Is the child open to seeking support from the family?
    • Is the family receptive to support outside the family?
    • Does the child’s support system allow and encourage them to mourn?

Professors David W. Kissane and Scealy M. Bloch of the School of Psychological Sciences in Victoria, Australia explored family functioning with the goal of 1) developing a typology of families and 2) identifying dysfunctional groups and those at risk of poor bereavement outcomes (1994).  Dysfunctional families in this context are those with barriers that impede a healthy reconciliation of their grief.  Barriers include, though are not limited to, lack of family support (perceived or actual), limited access to community support systems, and inappropriate coping skills (use of drugs and alcohol).  These authors also sought to examine any associations between family type and individual psychological and social morbidity. Results suggest that cohesion, expressiveness, and conflict are useful parameters in distinguishing adaptive families from those who cope poorly and whose members may go on to develop psychological morbidity (Kissane and Bloch, 1994).  This type of morbidity refers to low levels of functioning like listlessness or general malaise manifested over a period of time.

Kissane, et al (1996) describes the following family typology:

In supportive families cohesion is the striking quality of this group.  Members are intimate with each other, share their distress and provide mutual support.  They have low levels of psychological morbidity and function competently.

Hostile families are the most dysfunctional groups, which is indicated by high levels of conflict between family members.  Hostile family groups consisted of members with the highest levels of psychological morbidity and the poorest social adjustment.  It was common to find high numbers of offspring in this group.

Sullen families were the second most dysfunctional group characterized by moderate levels of conflict and a tendency to have poorer cohesion and expressiveness.  Sullen families exhibited high levels of psychological morbidity and were socially dysfunctional.  It was common to find depressive syndromes among family members.

Moderate levels of conflict, but high levels of cohesion and moderate expressiveness, characterized conflict resolvers.  This suggests that a degree of conflict, difference of opinion and negative feelings can be tolerated and is not in itself a marker of a dysfunctional status.

An intermediate range of cohesion, expressiveness and conflict characterized intermediate families. Members who were also less able to function well socially exhibited individual psychological morbidity. This group harbored sufficient morbidity to warrant intervention.

These authors further developed this work in a prospective longitudinal study that found the level of family functioning to be a powerful predictor of bereavement outcome (Kissane, Bloch, Dowe, 1997). In the case of parental death, the surviving spouse’s perception of overall family coping was a correlate of bereavement outcome on several dimensions: grief intensity, psychological distress, depression and social adjustment. When Kissane and Bloch saw family coping as poor, greater psychological morbidity ensued.  The dimensional scale of ‘overall family coping’ corresponds with the family typology reported in earlier work.

Other dimensions of social support, such as that received from friends, and time spent with friends and extended family members, also correlated with bereavement outcome; however, they were weaker than overall family coping.  Families with hostile and sullen typologies carry more psychological morbidity, and as such are at risk of complicated grief.

Factor Two: Sudden or Traumatic Death ~

Bereavement after a sudden or traumatic death can be more severe in nature and prolonged in recovery time. Sudden death is a devastating event that can make accepting the reality of loss an extremely difficult task for children and families. Sudden or traumatic death includes murder, suicide, fatal medical events, accidental deaths, drunk driving deaths, and, although frequently perceived differently by society, miscarriage, stillbirth, and Sudden Infant Death Syndrome (SIDS).

Stigmatized loss often leads to the bereaved feeling disenfranchised. There is a lack of general social support and validation of the grief response in survivors. The bereaved may have conflicting emotions about the deceased, vacillating between anger and an overwhelming sense of loss. Often, in cases of suicide, the survivors carry an intense feeling of self-blame, guilt or even rage regarding the person who has committed suicide.  Children and families can even face similar feelings when their loved one dies of a massive heart attack.  A child might think, “If Mommy wasn’t so stressed and overwhelmed by my bad behavior she wouldn’t have killed herself,” “If I had reminded Daddy not to eat bad foods, his heart wouldn’t have stopped,” or “The man was so stupid because he was drinking and driving and killed my brother.”

An unstable environment is immediately created in the child’s home, often leaving children confused and in turmoil. In the case of murder, it’s not unusual for family members to verbalize their desire for revenge, and some who articulate this desire in fact carry out this desire in one form or another. This is more far more prevalent in gang related deaths, though children cannot always separate “wishes of harm” from reality, and the youngest of children can then fear the caregiver they associate with the threat or act.

The role of the helper is especially critical after a sudden or traumatic death. There are four points to remember:

1)         Revisiting the notification of the death is important. Survivors need to tell their story of how they learned of the death.  It is important to be fully present when a child discloses this information, as they are entrusting you with their heart. The discussion will often move into not being able to say goodbye, anger, guilt and a wide variety of other topics that will need to be revisited when providing support.

2)         Screen children for feelings of severe helplessness and hopelessness.  Allow children to vent their anger at God, the deceased, surviving family members, and, in the case of accidents or murder, the person who caused the death.

3)         Educate the child and family regarding traumatic grief, including the common reactions of guilt, shame and self-blame.  Help them understand that it’s normal to try and affix blame, or try to find some cause for the experience.

4)         Reinforce a child’s and his family’s coping skills.  Revisit instances at school or home where they have felt successful. This is particularly important for children to develop a sense of control during an out-of-control situation in their lives.

Although there are commonalities in grief reactions, it’s important to recognize the uniqueness of each situation. There are considerable variables depending on the type of sudden or traumatic death the child has experienced. As previously discussed, factors like age, personality, developmental stage, earlier experiences with death, relationship with the deceased, cultural factors and family members’ ability to communicate with one another can all affect the situation.

Common Themes, Responses ~

    • No time to make changes
    • Often less information about the death and often delayed information
    • Impact on ability to cope
    • Loss does not make sense
    • Lack of understanding
    • Unfinished business
    • Unable to grasp situation
    • Violence of situation
    • Intentionality/preventability
    • Isolation, broken attachments, guilt
    • Suddenness
    • Disbelief
    • Seeking cause or reason
    • Terror, fear
    • Family’s participation in criminal justice system
    • Stigma: specifically with regards to suicide, or deaths related to domestic violence, drugs/alcohol.    Children may remain silent for fear of being ridiculed or ostracized.
    • Time can become ”frozen”
    • Dissociation
    • Revenge
    • Natural or man-made disasters
    • Who is responsible?
    • Post Traumatic Stress Disorder (PTSD)
    • Broken attachments
    • Media involvement
    • Disruption of the body
    • Medical examiner’s office/autopsies
    • Victimization and re-victimization
    • Trauma symptoms, acute stress disorders
    • Questioning: “Did daddy feel the pain?” “What was mom thinking?” “Did my brother know he was going to die?” “Was mom thinking of me?”
    • Meaning making which includes two types: “I am in charge of my life” or “That which is greater than we.” For example military deaths can make “more sense” because there      is meaning. “He/she loved what they were doing and they were protecting our country.”

Supporting Survivors, What to Expect ~ 

    • Intensity
    • Guilt
    • Shame
    • Helplessness
    • Anger/Rage
    • Confusion/Chaos
    • Agitation
    • Self-esteem shifts
    • Blame
    • Restlessness
    • Vulnerability
    • Flattened affect
    • “STUG” – Sudden temporary upsurges of grief
    • Physiological reactions

Factor Three: Complicated Grief ~

In her book Breaking the Silence, Linda Goldman explains complicated grief as “an unexpressed or unresolved important life issue – a frozen block of time – has created a wall of ice between the child and his or her grief. Our job is to help melt that wall” (1996, p. 7).

Goldman further states:

these frozen blocks of time stop the normal grief process, denying the child the ability to grieve.  It can feel as if life stops and time stands still. The natural flow of feelings is inhibited. There is no movement forward until the issues are resolved and the feelings released. Suicide, homicide, AIDS, abuse, and violence are familiar examples of situations that can lead to complicated grief.

The grief process is normal and natural after a loss. When children become stuck in this frozen block of time, they are denied access to this normal and natural flowing process. Overwhelmed by frozen feelings, the grief process seems to be “on hold” or nonexistent. The child is not in touch with his or her feelings of grief, or those feelings are ambivalent and in conflict with each other [1996, p.7]

Grief can be complicated by:

    • A sudden and unanticipated death
    • A death following a long illness
    • A troubled pre-morbid relations with deceased
    • Multiple deaths
    • A violent death (accident, suicide, homicide)
    • Personal vulnerability (e.g., poor self-esteem)

Accepting the reality can be difficult after a sudden death. It’s not uncommon for survivors to feel numb and shocked for weeks and even months. With these types of deaths, anxiety, fear, anger and panic are normal, and the perceived beliefs of preventability or randomness (road rage, drive by shooting) are ever present. These scenarios can sometimes cause internal conflict with the person who is trying to support the child. Provide children with a safe place to talk, think and play out their feelings.  Regardless of how uncomfortable you may be, partial answers to shield children from the truth, or providing answers that are inaccurate, are never appropriate.

To complicate this already difficult situation, the child and family can be dramatically impacted by victimization and re-victimization. Though it’s rarely intentional, first responders, media, and the judicial system can all negatively impact a family.   Children have little cognitive understanding of this type of impact, and regardless of how much a family attempts to insulate the child from the reality they are affected.

Even with the intervention of families, children can create their own stories that are often even more tragic than the facts.  Encourage family members to share with children the facts, depending upon what’s appropriate for their age group and where they are developmentally.

A child’s bereavement may be naturally complicated when the child experienced the deaths of two or more significant people in the same event, or the deaths of two or more significant people within a relatively short period of time.

Another significant factor to consider is the past relationship with the deceased.  Consider a child who lives in a home with domestic violence, abuse, alcoholism, or drug abuse.  Now consider a child who lives in a home with extreme expectations or one where the child feels unloved or unimportant.  Ambivalent feelings can occur in any of these situations. The child may feel relieved, even glad, to be rid of the expectations or abuse, yet ashamed to voice these feelings. The child may carry the secret of the abuse or perception of unmet expectations that becomes locked into the child’s memory, severely inhibiting the child’s ability to grieve in a healthy way.  Children often feel guilt, fear, abandonment, or depression when the grief of a loved one is complicated by an unresolved past.

Distrust in the world around them, and sometimes-even distrust in their caregivers and those who wish to support them can be present. Patience and dedication is key. These children can experience bereavement overload and have a higher incidence of permanent detachment.

When a child experiences bereavement overload, it is usually obvious that something is wrong. However, many caring adults find it difficult to admit that something is deeply disturbing a child. Professionals who have received little, if any, training to identify and help detached children can easily misdiagnose these children as well.

Dr. Ken Magid and Carol A. McKelvey (1987) authored a book entitled High Risk: Children Without a Conscience that provides an overview of the symptoms of detached children. Prior to his death in 2005 and posthumously, Dr. Magid was well-respected as a clinical psychologist, social science researcher, counselor and educator.  For more than 20 years, Carole McKelvey has been a therapist working with and researching Reactive Attachment Disorder (RAD):

    • Lack of ability to give and receive affection
    • Self-destructive behavior
    • Cruelty to other or to pets
    • Phoniness
    • Stealing, hoarding and gorging
    • Speech pathology
    • Extreme control problems
    • Lack of long-term childhood friends
    • Abnormalities in eye contact
    • Unreasonably angry parents
    • Preoccupation with blood, fire and gore
    • Superficial attractiveness and friendliness with strangers
    • Learning disorders
    • Incessant lying

There is still a significant amount of research that needs to be done about detachment disorders in children; however, experts in their fields like Magid & McKelvey, believe that it is important to get these children professional help as early as possible.  The older the child becomes, the more difficult it is to help him reattach to those around him.

Factor Four: Victimization and Re-Victimization ~

 Complicated grief can be further impacted by children and families who are victimized (treated unfairly) and re-victimized (victimization occurring at different points in time). Many first responders, medical community, therapists, psychologists and others supporting these families have often received little to no training in working with psychological trauma due to sudden, intentional death.

Victims are those impacted by a crime whether it’s directly or indirectly. They can either be the primary victim (person who died or suffered an injury, or a secondary victim). Consider a husband/father who was killed by a drunk driver.  His wife and children are secondary victims.  Now consider a family that was robbed.  Regardless if a death occurred of a family member, each is a victim.  If the assailants held a family member in the home and the others were not at home at the time, the person held in the home is the primary victim and the others who live in the home are secondary victims.  Regardless of the circumstances, each child or family member deserves to be treated with dignity, respect and compassion. One of the hopes of this manual is to enhance the helper’s skills to become the best possible advocate.

Victim injuries can include physical, financial, emotional and social. Physical injuries can range from minor to severe.  It’s important not to presume a child isn’t injured just because an injury isn’t visible. Consider injuries covered or hidden by clothing, or a child who suffers a brain injury. Somatic symptoms like stomachaches or headaches can be manifested, and in the case of a child with a disability this disability may become more severe after a crime.

For children, financial injuries are secondary, though they are affected by the consequences of additional financial pressure on the family due to damage of possessions, medical care, and time off work for counseling, court, or a physical/emotional injury.  These consequences can cause a great deal of hardship, particularly for a family whose loved one died because of a crime, and the primary victim was a breadwinner or primary caregiver for the children.

Emotional injuries are categorized as “feeling reactions.” Victims can experience shock, disbelief, and/or denial. Some victims including children may pretend the incident didn’t happen, and some child victims can regress in behavior and assume a more “childlike” state.

After some of the shock has worn off, victims can experience a vast array of confusing and even conflicting emotions.  These include: grief, fear/terror, anger/rage, confusion, guilt/self-blame, frustration, and shame/humiliation.

Social injuries are those caused by society.  This type of injury occurs when a victim is treated insensitively by a wide array of people.  More information regarding secondary victimization is below.

Children who are victims need safety, security, predictability, assurances, choices to help them feel in control, hope and affirmation that they did not cause the incident.

Secondary Victimization Can Be Caused By ~

    • Family & friends
    • Police/Fire
    • Criminal justice system
    • Media
    • Clergy
    • ER/Hospital
    • Medical Examiner
    • Social Services
    • Mental Health Professionals
    • Mortuaries

Individuals and institutions around the victim can cause post-crime harm. They may not intend to re-victimize a victim, however may do so because of fear for their own safety, lack of training and experience, or because they truly believe they are helping the victim.  Examples follow: 

Family and friends:      Blame, stigma, isolation, judgment, preconceived expectations.

Police/Fire:  Attitude, judgment, failure to utilize appropriate resources, failure to  provide victim’s rights information, insensitive death notification.

Justice system: Lack of information, hearing delays, lack of preparation. Family and possibly child may have to face perpetrator in court.

ER/Hospital:  Failure to provide treatment, failure to identify victimization as crime  related.

Clergy: Misguided compassion, “It was God’s will.”

Media: Publicizing victim’s name/address, invasion of private life, parallel stories, unwanted media attention and stories.

Medical Examiner: Poor death notification, insensitivity at crime scene.

Social Services:  Unavailable, insufficient training on victim issues.

Mental Health: Insufficient training on victim rights and issues.  Trust is critical, and help  can be perceived as “disconnected” to the issues or person.

Mortuaries: Possible stigma and treatment of crime victim families, insufficient training  on victim issues.

Trauma Compounded ~

Unfortunately, victims of certain crimes can be treated with less dignity because of who they are, socio-economic status, where they live, their belief systems, the nature of the crime, prior criminal history and a variety of other factors. Trauma can be compounded if someone is:

    • A child victim
    • A survivor of homicide
    • A witness of accidents, homicide or suicide
    • A racial minority victim
    • The victim of a catastrophic physical injury      (e.g., burns, loss of limb)
    • Physically/mentally challenged
    • Elderly
    • A rural resident
    • Gay or lesbian
    • A police officer or firefighter
    • A sexual assault victim
    • A domestic violence victim

Reasons for possible trivialization of these groups’ victimization and these victims compounded grief are as follows:

Children: Sometimes they are not considered reliable sources of information even if  they were present during the accident or situation. Children can feel as if they are ignored and inconsequential.

Homicide Survivor: Can have no role in the criminal justice system, may not be given information about the investigation. Survivors be stigmatized by friends and family, and exhibit feelings of guilt for surviving if someone else did not. They can blame themselves.

Witnesses: Might feel that they could have “stopped” the situation. May believe they  did not provide enough information to help “catch” the perpetrator.

Racial minorities: Face prejudice and systematic stratification and oversight.

Physical injury:  Often no support for all their needs.

Physically/Mentally:  Presumptions about skills/abilities. Training can be limited for service challenged:  providers.

Elderly:  Face age discrimination, are frequently isolated, and may already be experiencing a loss.

Rural victims: May lack access to services.

Police/Fire: May face the assumption that first responders can be callous, or have  experienced enough to be able to “deal” with the situation. 

Gay/Lesbian Victims:   Limited rights for partners, or presumptions about lifestyle. They may face social stigma.

Sexual Assault: May face the idea that the victim “caused” it by wearing a short skirt,  flirting, or acting in a promiscuous way.

Domestic Violence: Face attitudes such as: “It’s just emotional abuse; what’s the big deal?”  or “at least a bruise wasn’t left.” 

Factor Five: Secondary Loss/Adaptation Strategies ~ 

Loss of Self:

    • Self – “part of me died, too”
    • Identify – change in roles
    • Self-confidence – bereaved children can feel shame and suffer a lessened sense of self-esteem
    • Health – physical symptoms (stomachaches, or “I hurt everywhere”)
    • Personality – “I’m just not myself…”

Loss of Security:

    • Emotional – loved one is now gone
    • Physical – they may worry about who will care for their physical needs
    • Fiscal – family finances –  “Mom and Dad both worked, will Dad be able to pay for my soccer uniform?”
    • Lifestyle – home environment (physical and emotional may change)
    • Randomness of death 

Loss of Meaning:

    • Goals & dreams – goals can seem unreachable and goals shattered
    • Faith – “Why did God let my mommy die?”
    • Will/desire to live – “Why go on?”
    • Joy – happiness is compromised 

Environment:

    • Moving
    • Changing family structure
    • Family separation
    • Changing schools

External Objects:

    • Blanket or teddy bear destroyed in a fire or car accident
    • A favorite article of the deceased that was given to another family member 

Habits:

    • Regressive behaviors
    • Daily routines
    • Eating/sleeping patterns

Factor Six: Post-Traumatic Stress Disorder (PTSD) ~

It may be difficult in some situations to distinguish between the effects of the trauma and the presence of complicated grief.  Features of normal grief and PTSD may overlap, or PTSD may dominate.  One suggestion is that when trauma and grief co-exist, it is necessary to work though the effects of trauma before grieving can begin (Lindy, Green, Grace and Titchener 1983). This theory is reinforced by one study of children following exposure to a school sniper (Pynoos and Nadar, 1990). The study found that the trauma experienced was associated with PTSD, while grief correlated with the closeness of the relationship with the deceased children.

PTSD can develop when a person experiences an event beyond their ability to cope.  Children are especially vulnerable because they may not yet have learned, or put into practice, good coping techniques. These techniques include: seeking support, striving to maintain routines (especially for children), maintaining open dialogue, respecting each family member, and a variety of others. PTSD can occur several weeks, months, or even years after the event.  Many of the symptoms listed below are normal, but they need to be monitored.  If some of the following symptoms are observed, keep a record of your observations about the symptoms and their duration.  Watch for extremes of normal behavior as well.  If there is no evidence of improvement over time, it is advisable to refer the child to therapy.

Manifestations ~

    • Event flashbacks
    • Recurring and frequent nightmares
    • “Tuning out”, daydreaming
    • Numbness
    • Avoidance
    • Feelings of panic: “Mom said she’d be back in 15 minutes, she must be hurt or dead.”
    • Experiencing blank spots, or lack of recall
    • Preoccupation with death – their loved one’s or their own
    • Feelings of “survivor guilt” – “I should have died, too, or instead of…
    • Over-idealization of the deceased and distortion of the event.
    • Being overwhelmed with emotions: scared, out of control, tense, angry
    • Confusion about the sequence of events leading up to the event
    • Extreme irritability or outbursts of anger
    • Problems with drugs or alcohol
    • Inability to relax, being “on-edge,” high startle reflex
      • Physical or somatic symptoms such as cold sweats, rapid heartbeat, shortness of breath, stomachaches, headaches, etc.
    • Significant decrease in school and home activity
    • Detachment and withdrawal from family and/or friends
    • A strong death wish, with acting out dangerous behavior
    • Inability to experience emotions – to feel sad or happy

               (c) American Hospice Foundation