Counseling with children in contemporary society.

This article examines elements related to children's developmental understandings of death, ways to talk to children about death, a broad understanding of the nature of children's grief and bereavement, recognition of the common characteristics of grieving children, and useful interventions. The research related to the child grief process and the intrinsic value of therapeutic and educational supports in working with grieving children are discussed through case studies, the professional literature, and practical interventions that support the process of grief therapy for mental health counselors and the bereaved child.

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Grief counseling with children in contemporary society is a complex enterprise for mental health counselors (MHCs). Today's children are bombarded with loss in a way that many adults did not experience growing up. Common childhood losses are amplified by a world filled with terrorism, war, bullying, drugs, violence, sexuality, gender issues, and fear of nuclear or biological annihilation. Grief counseling with children benefits from the creation of a community grief team, whereby the parent or guardian, the school system, and the mental health counselor are part of an integral group that nurtures and supports the grieving child in an often confusing and unpredictable world. The purpose of this article is to address children's grief, focusing on their developmental understandings of death, ways to talk to children about death, the nature of children's bereavement, and the implications for mental health counselors. The research related to the child's grief process and the intrinsic value of supports through counseling and education in working with bereaved children is woven into this material. This information is presented through case studies, research, and intellectual understandings to support the process of grief therapy for mental health professionals and their clients.

BEREAVED CHILDREN

It is essential when working with children who have experienced the death of someone close to them to be aware of the many childhood losses incurred. Often there are secondary losses for bereaved children. The death of a loved one can be the catalyst creating many secondary losses including loss of friends, home, schools, neighborhoods, self-esteem, and routines. Angela was a 7-year-old in a single parent home. She rarely saw her dad after her parent's divorce. Mom had died in a plane crash. Within a week she moved to another state to live with her dad and a stepmother and stepbrother she barely new. Angela began to do poorly in school and said she "couldn't concentrate." She told her dad that she had no energy to play soccer anymore. She felt different now that her mom had died, and she "didn't want to talk about it with anyone." Within a short time she had lost her mom, her home, her school, her friends, her neighborhood, her ability to learn, and her day-to-day life as she knew it. These are multiple childhood losses that can occur due to the death of a parent.

MHCs' awareness of the following common losses experienced by children (Goldman, 2000b) can give insight into the complexities of children's grieving process. In addition to the types of losses that come easily to mind, like the loss of a family member or friend, children experience more subtle or less obvious losses. Other relationship losses include the absence of teacher or a parent being unavailable due to substance abuse, imprisonment, or divorce. Children experience loss of external objects through robbery or favorite toys or objects being misplaced Self-related losses include loss of a physical part of the body or loss of self-esteem perhaps through physical, sexual, emotional, or derivational abuse. Many children live with loss in their environment including fire, floods, hurricanes, and other natural disasters. A primary death can often create the secondary loss of a move, change of school, change in the family structure, or family separation. Other childhood losses are loss of routines and habits and loss of skills and abilities after the death of a close loved one. Lastly, the loss of a future and the protection of the adult world are common experiences for the grieving child, causing them sometimes to exhibit a lack of motivation and an inclination to choose violence as a way of solving problems.

Children's Developmental Understanding of Death

A child's understanding of death changes as he or she develops, as explained by Piaget's (Ginsberg, & Opper, 1969) cognitive stages of development. Gaining insight into children's developmental stages allows the MHC to predict and understand age-appropriate responses. During the pre-operational stage, usually ages 2-7, magical thinking, egocentricity, reversibility, and causality characterize children's thinking. Young children developmentally live in an egocentric world, filled with the notion that their words and thoughts can magically cause a person to die. Children often feel they have caused and are responsible for everything (Ginsberg, & Opper). For instance, 5-year-old Sam screamed at his older brother, "I hate you, and I wish you were dead!" He was haunted with the idea that his words created his brother's murder the following day. Due to Sam's age-appropriate egocentrism and magical perception, he saw himself as the center of the universe, capable of creating and destroying at will the world around him. Reversibility also characterizes children's grieving. For example, Jack, a 5-year-old first grader, was very sad after his dad died in a plane crash. Age-appropriately, he perceived death as reversible and told his friends and family that his dad was coming back. Jack even wrote his dad a letter and waited and waited for the mailman to bring back a response. Alice, age 7 years, who told me that she killed her mother, exemplifies the common childhood notion of causality in the following story. She was 4 years old when her mom died. When I asked how she killed her, she responded, "My mom picked me up on the night she had her heart attack. If she hadn't picked me up, she wouldn't have died; so I killed her."

Piaget's next stage of development, concrete operations, usually includes ages 7-12 years (Ginsberg, & Opper, 1969). During this stage the child, in relation to death, is very curious and realistic and seeks information. Mary, at age 10, wanted to know everything about her mother's death. She stated that she had heard so many stories about her mom's fatal car crash that she wanted to look up the story in the newspaper to find out the facts. Jason, age 11, wondered about his friend who was killed in a sudden plane crash. "What was he thinking before the crash, was he scared, and did he suffer?" Tom age-appropriately wondered at age 9 if there was an after-life and exactly where his dad was after his sudden fatal heart attack. These examples illustrate that, at this stage of development, children commonly express logical thoughts and fears about death, can conceptualize that all body functions stop, and begin to internalize the universality and permanence of death. They may ponder the facts about how the terrorists got the plane to crash, wanting to know every detail. When working with this age group, it is important to ask, "What are the facts that you would like to know?" and to assist children in finding answers through family, friends, media, and experts.

Adolescents' (age 13 and up) concept of death is often characterized in accord with Piaget's prepositional operations, implications, and logic stage of development (Ginsberg, & Opper, 1969). Many teenagers, being self-absorbed at this age, see mortality and death as a natural process that is very remote from their day-to-day life and something they cannot control.

Teenagers are often preoccupied with shaping their own life and deny the possibility of their own death. Malcolm, 16 years old, expressed age-appropriate thoughts when he proclaimed, "I won't let those terrorists control my life. I'll visit the mall in Washington whenever I want. They can't hurt me!"

Children can misinterpret language at different developmental stages. The young child can misunderstand cliches associated with grieving, and these cliches can actually block the grieving process. Sammy, at age 6, began having nightmares and exhibited a fear of going to sleep after he was told that his dog Elmo died because "the vet put him to sleep." Alice was told it was "God's will" that her grandmother died because "God loved her so much." Alice questioned, "Why would God take Grandma away from me, doesn't God love me, and will God take me too?" Tom, age 9 years, continually heard the message that dad was watching over him. One day he asked the mental health clinician, "Do you really think my dad is watching over me all of the time? That would be very embarrassing."

Talking to Children About Death

Sudden or traumatic deaths, divorce and abandonment, the death of a grandparent, and the loss of a pet are a few of the many grief issues that children face (Goldman, 2000b). These losses shatter the emotional and physical equilibrium and stability a child may have had. The terror, isolation, and loneliness experienced by too many of today's children after a death leave them living in a world without a future, without protection, and without role models. Children normally and naturally assume the adult world will care for them, support them, and nurture them. When Grandpa has a sudden fatal heart attack, Dad dies in a car crash, Mom dies of suicide, or sister Mary overdoses on drugs, a child's world is shattered. "How could this have happened to me?" is the first question.

Children need to know the age-appropriate truth about a death (Goldman, 2000b). They often have a conscious or unconscious knowing of when they are being lied to, and this knowing can create a secondary loss of the trust of their emotional environment. In talking with children, mental health counselors, parents, and teachers can define death as "when the body stops working." In today's world we need to provide specific definitions for children for different kinds of death. Suicide is when "someone chooses to make his or her body stop working," and homicide is "when someone chooses to make someone else's body stop working." MHCs can say, "Sometimes people die when they are very, very, very old or very, very, very sick; or they are so, so, so injured that the doctors and nurses can't make their bodies work any more." It is important to know that children ask questions such as "Will I die too?" The common questions that children ask about death and grieving give the MHC an insight into their process. The questions serve as a mirror to reflect the child's inner thoughts and feelings that might be otherwise hidden. By responding to questions like the following, the mental health professional or other adult can create an openness to grieve: (a) Who will take care of me if you die too?, (b) Will you and daddy die too?, (c) What is heaven?, (d) Can I die if I go to sleep?, (e) Where did grandpa go?, (f) Will it ever stop hurting?, (g) Why did God kill my mom?, (h) Will Grandpa come back?, (i) Will I forget my person?, (j) Did my person suffer?, and (k) Was it my fault?

Understanding the Nature of Children's Bereavement

Fox (1988) explained that one useful way to help bereaved children and monitor their ongoing emotional needs is to "conceptualize what they must do in order to stay psychologically healthy" (p. 8). Fox emphasized that, in order to assure children's grief will be good grief, they must accomplish four tasks: understanding, grieving, commemorating, and going on. Each child's unique nature and age-appropriate level of experience can influence how he or she works through these tasks. The specific cause of death can also influence the way a child accomplishes these tasks. A dad's death by suicide may create significantly different issues than an anticipated grandfather's death from pneumonia.

Bereaved children may not process grief in a linear way (Goldman, 2000b). The tasks may surface and resurface in varying order, intensity, and duration. Grief work can be "messy," with waves of feelings and thoughts flowing through children when they least expect it to come. Children can be unsuspectingly hit with these "grief bullets" in the car, listening to a song or the news, seeing or hearing an airplane overhead, reading a story in school, or watching the news about a terrorist attack. A fireman's siren, a jet fighter, a soldier in uniform, a postal letter, or a balloon bursting can trigger sudden and intense feelings without any warning, and often without any conscious connection to their grief and loss issue.

Common characteristics of grieving children. Children in the 21st century experience grief-related issues involving safety and protection that many adults may not have had as children. Whether children ever really enjoyed the protection of the adults in their lives is a debatable question, but the perception of that safety seems to have existed in previous generations. Although grief-related issues have always existed through time, today's children are exposed to an extraordinary visual and auditory barrage of input. The news, the World Wide Web, music, and videos are constantly bombarding children with sounds and images of school shootings, killings, violence, and abuse. Children are left with feelings of vulnerability and defenselessness. Either by real circumstances or vicariously through media reports, young people are inundated with issues such as murder, suicide, AIDS, abuse, violence, terrorism, and bullying that often hinder their natural grief processes. This disruption is an overlay for other interactive components that may affect a child's grief process.

Three categories of interactive components can be examined in assessing the grieving child (Webb, 2002):

* Individual factors

* Death-related factors

* Support system factors

The flowing and overlapping of these components create a complex world for the grieving child. Individual factors include cognitive and developmental age; personality components; past coping mechanisms in the home, school, and community environments; medical history; and past experience with death. Death-related factors involve the type of death, contact with the deceased such as being present at death, viewing the dead body, attending funerals and gravesite, expressions of "goodbye," and grief reactions. The third group of variables concerns the child's support system including grief reactions of the nuclear family and extended family; school, peer, and religious recognition and support of the grief process; and cultural affiliation including typical beliefs about death and the extent of a child's inclusion. Other factors related to a death that may increase complications for the grief process include suddenness and lack of anticipation, violence, mutilation, and destruction, preventability and/or randomness, multiple death, and personal encounter of the mourner such as a threat or shocking confrontation.

As noted by Webb (2002), "although virtually any death may be perceived by the mourner as personally traumatic because of the internal subjective feeling involved ... circumstances that are objectively traumatic are associated with five factors known to increase complications for mourners" (p. 368). Learning to recognize the signs of grieving and traumatized children is essential to normalizing their experience of grief and trauma. A mental health counselor needs to be educated in these common signs in order to reinforce for bereaved children, families, and educators that these thoughts, feelings, and actions are natural consequences in the child's grief process. This reassurance helps to reduce anxiety and fear.

Children may experience the following physical, emotional, cognitive, and behavioral symptoms common in the grieving process: The child (a) continually re-tells events about his or her loved one and their death; (b) feels the loved one is present in some way and speaks of him or her in the present tense; (c) dreams about the loved one and longs to be with him or her; (d) experiences nightmares and sleeplessness; (e) cannot concentrate on schoolwork, becomes disorganized, and/or cannot complete homework; (f) finds it difficult to follow directions or becomes overly talkative; (g) appears at times to feel nothing; (h) is pre-occupied with death and worries excessively about health issues; (i) is afraid to be left alone; (j) often cries at unexpected times; (k) wets the bed or loses his or her appetite; (1) shows regressive behaviors (e.g., is clingy or babyish); (m) idealizes or imitates the loved one and assumes his or her mannerisms; (n) creates his or her own spiritual belief system; (o) becomes a class bully or a class clown; (p) shows reckless physical action; (q) has headaches and stomach aches; and (r) rejects old friends, withdraws, or acts out.

Complications in children's grief. In addition, children's grief can be complicated, and common signs include withdrawal, sleep disorders, anxiety, difficulty in concentration, and regression. The common signs associated with children's bereavement may become heightened by their intensity, frequency, and duration. The term disenfranchised grief is used by Doka (1989) to refer to losses that cannot be openly acknowledged, socially sanctioned, or publicly mourned. Five categories of situations may create complications for the bereaved child (adapted with permission from Goldman, 2001). These categories are:

* Sudden or traumatic death

* Social stigma and shame

* Multiple losses

* Past relationship with the deceased

* The grief process of the surviving parent or caretaker

They explain circumstances that can create complications leading to obstructions in the child's grief process. Awareness of the commonality of feelings and thoughts surrounding these situations can aid the mental health counselor in normalizing what may seem so unfamiliar for the children.

Sudden or traumatic death can include murder, suicide, a fatal accident, or sudden fatal illness. With a sudden or traumatic death, an unstable environment is immediately created in the child's home. Children feel confusion over these kinds of death. A desire for revenge often is experienced after a murder or fatal accident. Rage or guilt, or both, emerge against the person who has committed suicide. A terror of violence and death unfolds, and the child feels shock and disbelief that suddenly this death has occurred.

Social stigma and shame frequently accompany deaths related to AIDS, suicide, homicide, terrorist attacks, or school shootings. Children as well as adults often feel too embarrassed to speak of these issues. They remain silent out of fear of being ridiculed or ostracized. These suppressed feelings get projected outward in the form of rage or inward in the form of self-hatred. Often times these children feel lonely and isolated. They cannot grieve normally because they have not separated the loss of the deceased from the way the deceased died.

Multiple losses can produce a deep fear of abandonment and self-doubt in children. The death of a single parent without a partner is a good example of a multiple loss. When the only parent of a child dies, the child can be forced to move from his or her home, the rest of his or her family and friends, the school, and the community. The child is shocked at this sudden and complete change of lifestyle and surroundings, and may withdraw or become terrified of future abandonment. Nightmares and/or bed-wetting could appear.

The past relationship to the deceased can greatly impact the grieving child. When a child has been abused, neglected, or abandoned by a loved one, there are often ambivalent feelings when the loved one's death occurs. A 5-year-old girl whose alcoholic father sexually abused her may feel great conflict when that parent dies. Part of her may feel relieved, even glad, to be rid of the abuse yet ashamed to say those feelings out loud. She may carry the secret of the abuse and become locked into that memory and be unable to grieve. Children often feel guilt, fear, abandoned, or depressed if grief for a loved one is complicated by an unresolved past relationship.

The grief process of the surviving parent or caretaker greatly affects children. If the surviving parent is not able to mourn, there is no role model for the child. A closed environment stops the grief process. Many times the surviving parent finds it too difficult to watch his or her child grieve. The parent may be unable to grieve him or herself or may be unwilling to recognize the child's pain. Feelings become denied and the expression of these feelings is withheld. The surviving parent may well become an absentee parent because of his or her own overwhelming grief, producing more feelings of abandonment and isolation in the child. Children often fear something will happen to this parent or to himself or herself and, as a result, become overprotective of the parent and other loved ones (Goldman, 2001).

IMPLICATIONS FOR MENTAL HEALTH COUNSELORS

There are important general purposes for the MHC when working with grieving children. A major purpose is allowing children freedom to express emotion. This expression of emotion is an integral component of counseling and includes interventions with writing, drawing, poetry, projective techniques, and dream work. Support groups for children enhance the expression of emotions with peers who are working through similar situations Allowing children to connect to and maintain memories serves as another important purpose for the MHC professional. Through remembering and sharing with others, the bereaved child can maintain a continuing bond with the person who died. Educating grieving children and the adults around them underscores another purpose for the mental health counselor: To create common thoughts and practices that harmoniously integrate the network of support surrounding the bereaved child.

Identifying At-Risk Children

Grieving children wonder if the pain will ever stop hurting. As Celotta, Jacobs and Keys (1987) identified, two questions that at-risk children respond to 100% of the time are: "Do you feel hopeless?" and "Do you feel sad?" These responses were part of a checklist given to elementary school children to identify depression. Mental health counselors can create simple tools to help target children who are traumatized and may be at-risk. Asking them to write or draw in response to questions such as "What makes you the most sad?," "What makes you the angriest?," or "What makes you feel the loneliest?" can provide useful information. Jin, a 10-year-old student from China, explained his picture showing a boy with his soul next to him. His older brother had recently died of suicide. Jim explained, "This is me, and this is my soul. Sometimes I feel like killing myself so I won't feel all of the pain. Sometimes I wish I would just disappear." This simple intervention created the identification of an at-risk child and pointed out the need for further exploration and evaluation.

Interventions for Individual Counseling

"The goal of helping children of all ages to cope with death is to promote their competence, facilitate their ability to cope, and recognize that children are active participants in their lives" (Silverman, 2000, p. 42). Mental health counselors need to be prepared to respond to children's questions. Grieving children are becoming a larger and larger, growing segment of our youth; and their grief issues arise at younger and younger ages. Not that long ago, parents were advised to exclude their children from memorials and not talk to them about death or about feelings about their loved one. Today, mental health professionals can emphasize the importance of seeing children as recognized mourners and as an integral part of the family system's bereavement process. Mental health counselors can speak, share, and create a space for young people to freely participate in the family's mourning. The MHC's goal is to allow safe expression of children's grief responses in a respectful environment. Grief-resolution techniques are important to create and stimulate discussion and exploration of thoughts and feelings, because bereaved children cannot always integrate their emotions and their intellect. While the MHC is building a relationship of trust, children also experience support and affirmation in an atmosphere that honors and respects them. The following techniques allow them to spontaneously and safely work through difficult spaces at their own comfort level. Healing is promoted when children put their feelings outside of themselves (Goldman, 1998a).

Expression of feelings. There are several interventions that are useful for helping children to express themselves. Worry lists, letter writing, reality checks, worry and safe boxes, drawing, and poetry are all valuable interventions with children. Projective techniques and dream work are interventions that allow release of thoughts and feelings in verbal and nonverbal ways.

One of the common signs of grieving children is that they worry excessively about their health and the health of the surviving parent or guardian. Roxanne, 10 years old, had multiple deaths in her family and worked in grief therapy for many months. In one counseling session, she seemed worried and agitated. When asked to list her five greatest worries, her first was a concern she had never mentioned until that moment: "I'm so scared my dad will die too! He smokes and I want him to stop." She burst into tears. Roxanne decided to write her dad a letter to express her feelings; and after being given the choice to send it or not, she decided to give it to him. Her anger and frustration are obvious in the letter:

   Dear Dad, You know how I feel about you smoking right now. You
   know how many losses I've had already ... I don't want you to
   go next. I really worry about you; so please stop smoking. I
   feel like ripping your head off to make you stop. Think before
   you buy so many cigarettes. Love, Roxanne P.S. Write me back.
   (Goldman, 2000b, p. 69)

Seven-year-old Brian's dad died in a sudden car crash. He confided during one session, "I'm worried my mom will die too. I think about it at school and before I go to bed." An intervention Brian found comforting was a reality check at mom's doctor. She had a complete check up and asked the doctor to write a note to Brian to reassure him that morn seemed healthy. This note provided a concrete and tangible linking object that comforted his worry about his mom's health. The letter read, Dear Brian, I wanted to let you know that your mom had a complete physical exam and she seems to be very healthy. Dr. Jones."

Margie's dad was killed in the Pentagon attack. She began having nightmares and had great difficulty sleeping. She decided to create a safe box, with objects inside that made her feel safe and peaceful. She decorated her box in grief therapy, using magazines and stickers, to create images that were calming to her. Inside her box, she put a favorite stuffed animal; her dad's medal from the military; a picture of her dog, Snuffy; and a bracelet her best friend Tanya had given her. Margie put her safe box on her dresser in her bedroom where it made her feel better whenever she went to it.

Adam, a 13 year old, witnessed his brother being killed in a ride-by shooting. He was bombarded with stimuli that re-triggered his panic about the violent way his brother died. Loud noises, sirens, and even the burst of a balloon could immediately begin difficult feelings of panic and anxiety for him. One intervention that he found soothing was the creation of a worry or fear box in which he could place his fears. Adam drew pictures and found slogans that illustrated things that made him scared. Drugs, guns, and terrorists were a major theme. He cut a hole in the top of his box and began placing little notes, his own private fears, inside. Sometimes he shared them, but other times he did not. Writing down his fears was a first step for Adam to begin to identify and cope with them.

Writing, drawing, and poetry are useful interventions for expression of feelings for the bereaved child. They serve to allow safe release of often hidden feelings. Writing was useful for 8-year-old Julia whose best friend, Zoe, and Zoe's family died in the terrorist attack. The following is a part of a poem she created as a tribute to her friend in her memory book. "Julia. Remembers by memories and hearing her name. Who wishes for peace and unity. Strong" (Goldman, 2003, p.146). Tyler's best friend Juan was killed in a car crash. He drew a picture of one of his favorite memories with his friend Juan. They were playing soccer at the park and fell, and they both burst into laughter. Tyler said that, when he looked at his picture, he felt happy. Andrew was 16 years old when his grandfather and his favorite aunt died. His grief was coupled with his sadness as he watched family members grieve too. He expressed his grief through poetry in the following way: "Tears flow--As time passes--The relatives grieve--In love for the deceased (Andre Burt, personal communication, December 11, 2001).

Middle and high school students may successfully respond to writing in locked diaries. Melissa was a teenager who came to counseling after the suicide of her older brother Joey. The shame she felt about the way her brother Joey died made it difficult to discuss complex feelings openly. She mentioned in session that she loved her diary, and kept it under her bed locked, safe, and private. She wrote her "sacred" thoughts and feelings in her diary. She used her diary not only as a safe receptacle for feelings, but also as an avenue for expression she could choose to use according to her readiness.

Projective play and dream work are grief interventions that allow children to use their unconscious mind and their imagination to safely express thoughts and feelings (Goldman, 2001). Young children learn through play, and they also grieve through play. Role-playing, puppets, artwork, clay, and sand table work are a few of the many ways that they can imagine, pretend, and engage in meaningful activities that allow them to act out or project their grief feelings without having to directly verbalize them. Play therapy is especially useful with bereaved children. Children have a limited verbal ability for describing their feelings and a limited emotional capacity to tolerate the pain of loss, and they communicate their feelings, wishes, fears, and attempted resolutions to their problems through play (Webb, 2002). Projective play allows many young children to work through difficult times. Having props such as helping figures, puppets, costumes, and building blocks allows children to recreate their experience and role-play what happened and ways to work with what happened. Bereaved children feel empowered when they can imagine alternatives and possible solutions, release feelings, and create dialogue through projective play.

Sometimes, what may appear as a frivolous play activity can be an extremely meaningful outlet for children to recreate an event and safely express conflicting ideas. For example, 6-year-old Jared was very sad in a beginning grief therapy session. He missed his dad, who was killed in a car accident. He walked around the office, talking about how much he missed Dad and that he wished he could talk to him. Jared picked up a toy telephone and followed the mental health professional's suggestion that he call and tell him how he feels. Jared sat down on the floor, dialed the number, and began an ongoing, very present conversation with his dad including "Hi Dad. I love you and miss you so much. Are you ok? Do you miss me? I hope heaven is fun and you can play baseball there. Let me tell you about my day." Children may commonly reach out to initiate a connection to their deceased parent. Through projective play, Jared was able to feel he could communicate in a satisfying way with his father. Alex, who was bereaved in the Sept. 11th terrorist attack, spontaneously built towers of blocks to represent the Twin Towers, and then knocked them down with an airplane. When replaying the attack and the fairing of the towers, Alex explained, "Airplanes make buildings go BOOM!" Allyson, a kindergartner, suffered the tragic death of her morn at the Pentagon. She created a cemetery out of blocks and explained what was bothering her through the use of toy figures. She reported, "When me and Daddy visit the cemetery I wonder about Mommy. There was no coffin or body at the cemetery. I wonder where my Mommy's body is now." Play allowed the expression of deep concern about her mom's body and opened communication about this in the therapeutic environment. Allyson agreed to share her block cemetery and questions about mom with dad, as a way to begin to answer them. Michael, age 5 years, recreated the disaster setting of his dad's death. Dad was inside his office when a tragic fire took his life. Using toy doctors, nurses, fireman, and policeman as props, he pretended to be a rescue worker and saved his dad. Then he put on a fire hat and gloves and shouted, "Don't worry I'll save you. Run for your life."

Puppets and stuffed animals are also a safe way for children to speak of the trauma through projecting thoughts and feelings onto props, and dream work is another tool allowing children to process difficult feelings. For example, the MHC might inquire of a bereaved child, "I wonder what Bart (the dog puppet) would say about the trauma. Let's allow Bart to tell us about his story." In addition, children often feel survivor guilt after a sudden death (Worden, 1991). In dreams, sadness and depressing thoughts and feelings surface, accompanied by guilt that the child has survived, another person has died, and the child did not or could not help the deceased. Justin, a 10-year-old, explained a common theme in his dream. Justin continually revisited a nightmare after Uncle Max suddenly died during his military deployment. He shared his dream with his mental health professional and drew a picture showing his uncle calling out for help and Justin being unable to reach him.

Connecting to and maintaining memories. Silverman, Nickman, & Worden (1992) found that it was normal for children "to maintain a presence and connection with the deceased and that this presence is not static" (p. 495). The bereaved child constructs the deceased through an ongoing cognitive process of establishing memories, feelings, and actions connected to the child's development level. This inner representation leads to a continuing bond to the deceased, creating a relationship that changes as the child matures and his or her grief lessens. There are five strategies of connection to a deceased parent: (a) making an effort to locate the deceased, (b) actually experiencing the deceased in some way, (c) reaching out to initiate a connection, (d) remembering, and (e) keeping something that belonged to the deceased.

Those MHCs who work with bereaved children "may need to focus on how to transform connections and place the relationship in a new perspective, rather than on how to separate from the deceased" (Silverman et al., 1992, p. 503). In locating the deceased, many children may place their loved one in a place called "heaven" (p.497). Michelle was 7 years old when she began in counseling. Her mom had died in a sudden car crash. One day Michelle asked in session, "What do you think heaven is?" Reflecting Michelle's question, the mental health professional asked, "What do you think it is?" Both began to draw a picture of their image of heaven. This intervention helped Michelle reflect on her own question, and she was able to remember her mother by sharing the place where she thought Mom was. It was also a way to honor Morn, express things about Morn, and symbolically again tell Mom how much she loved her. In addition, Michelle wrote the follow story about heaven:

   What is heaven? This is what heaven is to me. It's a beautiful
   place. Everyone is waiting for a new person, so they can be
   friends. They are also waiting for their family. They are
   still having fun. They get to meet all the people they always
   wanted to meet (like Elvis). There are lots of castle where
   only the great live, like my Mom. There's all the food you
   want and all the stuff to do--There's also dancing places,
   disco. My morn loved to dance. I think she's dancing in heaven.
   Animals are always welcome. (My Mom loved animals.) Ask her how
   Trixie is. That's her dog that died. Tell her I love her.
   (Goldman, 2000b, pp. 79-80).

Memory books, memories boxes, and memory picture albums can all be used to address bereaved children's questions of "Will I forget my person?" Memory work is an important part of the therapeutic process. Children often fear they will forget their person who died, and memory work can provide a helpful tool to safely process the events of their grief and trauma. Memory books store pictures and writings about loved ones; memory boxes hold cherished objects belonging to a special person; and memory picture albums hold favorite photographs. Mental health counselors can ask children the following questions as a foundation for discussion and processing memories after a death: (a) Where were you when your person died?, (b) What was your first thought?, (c) What are the facts about how your person died?, (d) What makes you sad, happy, angry, frustrated?, (e) What sticks with you now?, (f) Did you do anything wrong?, (g) What is it you still want to know?, (h) What scares you the most?, (i) What makes you feel peaceful?, and (j) What can you do to feel better?

Memory books are extremely useful tools to allow children to express feelings and complete unfinished business, including feelings and thoughts that boys and girls were unable to communicate at the time of their person's death. Inside a memory book, grieving children can use stars, stickers, photographs, and other decorations to expand their own writings and drawings about their person. These are a few suggestions about various themes for memory book work: (a) The most important thing I learned from my person is ..., (b) What was life like before your person died?, (c) What is life like now?, (d) My funniest memory is ..., (e) My most special memory is ..., (f) If I could tell my loved one just one more thing, I would say ..., and (g) If I could say one thing I was sorry for it would be ... (Goldman, 2000b). For example, Alfred, age 10, made a memory book page illustrating the events of September 11, 2001. It was his attempt to make sense of his world after the disaster. His memory page was a picture that helped him release feelings, tell stories, and express worries and concerns. The picture he drew showed where he was and what was happening at his New York school situated so close to ground zero. His only message was "Run for your life." With this memory book page, Alfred was able to begin to release some of the terror he felt that day at being so close to the Twin Towers as he also told his story.

Memory boxes are an excellent craft project for grieving children. They can be used to hold special articles, linking objects that are comforting because of belonging to or being reminders of the person who died. These objects can be put in a shoebox and decorated by the child as a valuable treasure of memories, which is also a tool for stimulating conversation. Memory boxes serve as a linking object by holding something that belonged to the deceased. These linking objects help the child maintain his or her connection or link to his or her loved one (Silverman et al., 1992). For instance, Tanya, an 8-year-old, made a memory box with pictures and special objects that reminded her of her friend Angie who died in a sudden plane crash. Tanya included pictures, stuffed animals, a list of her top favorite memories, and a bracelet her friend had given her. She explained that it made her "feel good" whenever she held it and she loved to share it with her friends and family. The memory box created a place where Tanya could "be with her friend Angie."

Creating memory picture albums with children titled "My Life" is often an extremely useful tool in creating dialogue and sharing feelings. Henry's dad died of cancer when he was 11. Henry created his memory album by choosing pictures he loved to make an album about his life before and after dad died. He placed each picture in his book and wrote a sentence telling about it.

Children love to express memories through artwork. Memory murals and memory collages are examples of memory projects that are helpful therapeutic interventions for grieving children. Children can creatively express feelings and thoughts about their loved ones. Fifteen-year-old Megan prepared a collage of magazine pictures that reminded her of her best friend, Ashley, who had recently died of cancer. She included Ashley's favorite foods, favorite clothes, favorite music, and favorite movie stars. Zack, age 9 years, was a best friend to Andrew, who had died when he was 6. Zack drew a picture for the cover of Andrew's third memorial booklet, "On the Occasion of Andrew's Third Anniversary." He explained that his drawing showed Andrew "shooting hoops in heaven." He felt in the few years since Andrew's death, he had been playing basketball, and assumed Andrew was doing the same in heaven. By participating in the memorial booklet, and being given a voice to explain his work, Zack was able to continue to actively remember his friend and participate in on going involvement with memory work.

Memory e-mails are a creative example of memory work and computer use. After 14-year-old Donald's classmate Ethan got killed in a car crash, Donald and his classmates decided to create a chat room only for e-mail memories about Ethan. They also created a memory video of Ethan, using a popular rock group as a background for a montage of pictures of Ethan from birth until he died, including friends, pets, and family.

Using children's grief and loss resources is an excellent technique to allow discussion and expression of sometimes hidden feelings. It's often reassuring to bereaved children to read words that speak of the loss they have experienced and the many new feelings they have associated with grief. Children's resources can become a helpful tool for parents. These books create meaningful discussion and often allow adults to dialogue about their common loss issues (Goldman, 2000b). A few examples of useful books for children on grief are: When dinosaurs die (Brown & Brown, 1996), When someone very special dies (Heegaard, 1988), Bart speaks out: Breaking the silence on suicide (Goldman, 1998a), Honoring our loved ones: Going to a funeral (Carney, 1999), and After a murder: A workbook for kids (The Dougy Center, 2002). Suggestions for useful books for grieving teens include: Death is hard to live with (Bode, 1993), When a friend dies (Gootman, 1994), Facing change (O'Toole, 1995), and Fire in my heart, Ice in my veins (Traisman, 1992). Readers can contact the author for a more complete list.

Support Groups

Many bereaved children feel alone and find peers and family members so often want them to move on and stop talking or even thinking about their person (Goldman, 2000b). They wonder who they can really talk with about their morn or dad or sister who has died. Often they feel different and choose not to share. Grief support groups can provide a safe haven for them to explore their overwhelming and often confusing feelings with others that understand because they are going through a grief process also. Becoming a member of an age-appropriate grief support group allows children and teens a safe place to share with others and create friendships.

Education

If mental health counselors can join together with parents, educators, therapists, and other caring professionals to create a cohesive unit, sharing similar thought forms, supports, resources, and information, a child's grieving experience becomes more congruent. Usually when children grieve, their world feels fragmented. The more consistency MHCs can create within children's lives, the more solid and secure their world will become. The role of mental health counselors as liaisons to parents, educators, and community members is an important aspect of children's grief therapy. Educating caring adults provides a united multiple support system for the grieving child.

Mental health professionals can educate surviving parents and guardians on common signs of grieving children and coach the adults on how to reduce the children's fear and anxiety about new thoughts and feelings. This education helps adults reduce their own anxieties that can unconsciously be projected onto their children. MHCs can provide age-appropriate words to help family members create open dialogue and identify their own unresolved grief and the impact of their grieving process on their children. For example, 15-year-old Mark lived with his grandmother after his mom's death. Grandma often told the mental health professional that she was concerned because Mark "doesn't seem to be grieving." One day in a seemingly unrelated conversation, she mentioned that Mark takes a nap every day on his mother's bed. Grandma was unaware that grieving teens commonly reach out to initiate a connection with their person who died (Silverman et al., 1992). That connection may well be taking a daily nap on mom's bed.

The MHC can also be an advocate for the grieving child in the school system. This advocacy can offer suggestions to educators, who are working with bereaved children, as a support after their person's death. Because children are sometimes flooded with feelings and are not immediately able to verbalize them, MHCs can work with educators in developing strategies for children to follow when they feel upset. In doing so, MHCs can emphasize the importance of the child being part of the decision-making process in choosing appropriate people or places they are comfortable with to be used to implement these strategies. These ideas can be implemented throughout the school year and continued for the next year if necessary. Suggestions include any or all of the following (Goldman, 1998b). The child (a) has permission to leave the room, if needed, without explanation, (b) can choose a designated adult or location within the school as a safe space, or (c) can call home if needed. Amy, who worried about Mom after Dad died, provides an example of how this might occur. She thought about her Mom a lot in the mornings and chose to call home at that time to make sure she was all right. Other strategies include the child's having (a) permission to visit the school nurse if needing a reality check, (b) a class helper, (c) private teacher time, (d) some modified work assignments, and (e) school personnel inform faculty, PTA, parents, and children of the loss. In addition, it may be useful to give the child more academic progress reports such as was done for Henry who had a hard time concentrating after his brother Sam died (Goldman, 2000a). Henry could not remember as well and found his test scores declined. Having frequent progress reports helped him keep his studies on track.

The MHC serves as a liaison to the school system to inform those involved that there is a grieving child in the school. Presenting a loss inventory (Goldman, 2000a) that can be shared with educators is a helpful tool for communication within the school. All too often school systems do not communicate to their entire staff that a child has experienced the death of a close loved one. This lack of knowledge can create trauma and an added layer of sadness for students. Liam was a fifth grader who was star athlete for the soccer game. Many parents and friends had gathered to watch the team in their tournament finals. Coach McGuire approached Liam before the game and asked, "Is your dad here today?" "No," Liam grumbled. He had to work" Liam played his worst game. Coach McGuire was unaware that Liam's dad had died recently; there was no written record to communicate this within the school. If this school system had an established practice of using a loss inventory, this lapse in communication and its devastating impact on Liam may not have occurred.

A grief therapy homework assignment, which can be used even in educational or advocacy situations, can help children and teens identify their individual support systems. Children can be asked to create a "circle of trust," placing a picture of themselves in the center and three trusted people with their phone numbers that they can call for support. They can create a second circle for people they would call next. They may even create a third circle for people they know they cannot trust. Their circle of trust can stimulate dialogue in therapy as well as serve as a tool for recognition of those they can and cannot count on for support during their present loss (Goldman & Rosenthal, 2001).

Childhood Commemoration

Children become recognized mourners when adults create ways for bereaved children to ask questions and share thoughts and feelings about death. Adults can also prepare and invite children to participate in funerals, memorials, and other rituals. When children can attend a memorial service they gain a great gift, the gift of inner strength (Goldman, 1996). It assists their grief process to be included in the funeral and other rituals associated with the death of a loved one (Rando, 1991). Knowing they could participate and be present with adults in a community remembrance of a friend or family member gives them awareness of how people honor a life, come together for each other as a community, and say good-bye. Honoring a life gives children a way to value and respect their own lives. They become identified mourners and an ever present and integral part of the grief process. Research indicates that children who were allowed to attend the funeral of a loved one later expressed positive feelings about going and about the meaning they attached to their attendance (Silverman & Worden, 1992). Children in the study felt "it was important to them that they had attended. Attendance helped them to acknowledge the death, provided an occasion for honoring their deceased parent, and made it possible for them to receive support and comfort" (p. 319). This nurturing environment supports their emotional and spiritual growth as human beings. So often caring adults are too uncomfortable talking to children about death. They may not have the words to use, may feel powerless when children are sad or cry, and ultimately may inhibit tears and stop the grief process.

Bereaved children can actively commemorate their loss by participating in safe and comfortable processes that allow for the expression of grief (Goldman, 1996). The following are age-appropriate ways children and teens can give meaning to their many thoughts and feelings. They can plant a flower or tree, send a balloon, blow bubbles, or say a prayer. Bereaved children might light a candle or write a poem, story, or song about their loved one and share it. Some boys and girls find talking into a tape recorder or creating a video of memories is helpful. Others enjoy (a) making cookies or cakes and bringing them to the family of the person who has died, (b) creating a mural or collage about the life of the person who has died, or (c) drawing a picture or making a memory book. Christina and Christy were two young children who were prepared, invited, and given choices about joining in a memorial service for their friend, Andrew. They were an active part of the service, sitting with family members, blowing bubbles, sharing, listening, and drawing pictures for their friend.

CONCLUSION AND RECOMMENDATIONS

Research suggests that certain mental health outcomes may emerge for grieving children (Lutzke, Ayers, Sandier, & Barr, 1997). Bereaved children may show (a) more depression, withdrawal, and anxiety; (b) lower self-esteem; and (c) less hope for the future than non-bereaved children. Adults who were bereaved children tend to exhibit higher degrees of suicide ideation and depression and are more at risk for panic disorders and anxiety. Support for bereaved children is essential in helping to reduce negative outcomes related to unresolved or unexplored grief during childhood. The findings suggest that, although trauma associated with death-related situations could not always predict later symptom formation, therapeutic intervention at the time of the death may help to reduce or extinguish future anxiety that could escalate without intervention.

A key debilitating factor creating ongoing trauma for grieving children is often a sense of loss of control in their lives. Early interventions through counseling and grief support groups can help boys and girls regain their sense of control and reduce the stress associated with the death of a friend or family member. Early interventions may also support children in their grief by providing a meaningful relationship with at least one caring adult (e.g., the MHC). Mishara (1999) reported that children with strong social supports have a reduced presence of suicide ideation. Another study (U.S. Secret Service, 2002) clearly indicates "the importance of giving attention to students who are having a difficult coping with major losses ... particularly when feelings of desperation and hopelessness are involved" (p. 14).The report suggests that an important aspect in prevention may be to allow young people the opportunity to talk and connect with caring adults.

The MHC needs to view him or herself not only as a therapist, but also as an advocate for bereaved children. MHCs' role as an ally and friend creates a link to the child's larger community that extends to parents, clergy, educators, physicians, and other health care professionals. Educating members of these supportive networking systems in the common signs of bereaved children and suggesting age-appropriate interventions can extend the boundaries of mental health services into the child's home, school, and community. MHCs are trained to see the child in the present and to view changes in behaviors as a cry for help. Using therapeutic interventions such as projective techniques, sharing, and listening allows children to work through their grief. Active involvement in commemoration, rituals, and support groups facilitates the healing process of the bereaved child. Giving boys and girls the opportunity to release their emotions within a safe haven is the underlying thread inherent in counseling grieving children.

REFERENCES

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Brown. L., & Brown, M. (1996). When dinosaurs die. New York: Little, Brown.

Carney. K. L. (1999). Honoring our loved ones: Going to a funeral. Wethersfield, CT: Dragonfly.

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Goldman, L. E. (1996). We can help children grieve: A child-oriented model for memorializing. Young Children: The National Association for the Education of Young Children, 51, 69-73.

Goldman, L. E. (1998a). Bart speaks out: Breaking the silence on suicide. Los Angeles, CA: Western Psychological Services.

Goldman, L. E. (1998b). Helping the grieving child in the school. Healing Magazine, 3, 15-24.

Goldman, L. E. (2000a). Helping the grieving child in the school Bloomington, IN: Phi Delta Kappa International.

Goldman, L. E. (2000b). Life and loss: A guide to help grieving children (2nd ed.). New York: Taylor & Francis.

Goldman, L. E. (2001). Breaking the silence: A guide to help children with complicated grief suicide, homicide, AIDS, violence and abuse (2nd ed.). New York: Taylor & Francis.

Goldman, L. E. (2003). Talking to children about terrorism. In M. L. Licht & K. J. Doka (Eds.), Living with grief, coping with public tragedy (pp. 139-149). Washington, D.C. Hospice Foundation of America.

Goldman, L. E. (2001). Circle of trust: Support for grief. In H. G. Rosenthal (Ed.), Favorite counseling and therapy homework assignments (pp. 108-110). New York: Taylor & Francis.

Gootman, M. (1994). When a friend dies. Minneapolis, MN: Free Spirit.

Heegaard, M. (1988). When someone very special dies Minneapolis, MN: Woodland.

Lutzke, J. R., Ayers, T. S, Sandier, N. S., & Barr, A. (1997). Risk and interventions for the parentally bereaved child. In N. Sandier, & S. Wolchik (Eds.),Handbook of children's coping: Linking theory and intervention (pp. 215-242). New York: Plenum.

Mishara, B. (1999). Conceptions of death and suicide in children ages 6-12 and their implications for suicide prevention. Suicide and Life-Threatening Behavior, 29, 105-118,

O'Toole, D. (1995). Facing change. Burnsville, NC: Compassion Books.

Rando, T. (1991). How to go on living when someone you love dies. New York: Bantam.

Silverman, P. (2000). Never to young to know: Death in children's lives. NY: Oxford University.

Silverman, P., Nickman, S., & Worden, J. W. (1992). Detachment revisited: The child's reconstruction of a dead parent. American Journal of Orthopsychiatry, 62, 494-503.

Silverman, P., & Worden, J. W. (1992). Children's understanding of funeral ritual. Omega, 25, 319-331.

Traisman, P., S. (1992). Fire in my heart: Ice in my veins. Omaha, NE: Centering.

U.S. Secret Service, (2002). Preventing school shootings: A summary of U. S. Secret Service Safety school initiative. National Institute of Justice Journal, 248, 10-15.

Webb, N. B. (Ed.). (2002). Helping bereaved children: A handbook for practitioners (2nd ed.). New York: Guilford.

Worden, J. W. (1991). Grief counseling and grief therapy: A handbook for the mental health practitioner. New York: Springer.

Linda Goldman, CLPC, CT, is a grief therapist, author, and adjunct faculty at John Hopkins University, Baltimore, MD. E-mail: [e-mail]