Expand mission by training educators
Grieving children need plenty of help
It’s difficult for hospices to reach children who may be grieving over a parent’s death. Often a parent dies suddenly without hospice care. In larger cities, there simply may be too many children for a hospice to handle.
"We receive so many referrals of children that we just cannot accommodate all the grief that’s out there," says Honi Weiss, vice president of fundraising and community relations for The Center for Hospice Care in Glen Ridge, NJ. The hospice provides services to 10 counties in northern New Jersey and an affiliate of the St. Barnabas Health Care System in Livingston, NJ.
A rising tide
Hospice officials decided to create a community outreach program to provide children and their guardians with the counseling and care they need. The child-parent program, called Changing Tides, is for school personnel. It includes a 235-page manual and an 11-minute video.
"It gives the school professionals tools to handle grieving children in a less self-conscious and more open way," Weiss says. "It also addresses suicide, murder, and AIDS, because in our cities today, people face those realities all of the time."
"The purpose of writing this manual was to help school professionals start groups in their schools," says Estelle D’Costa, MSW, LCSW, ACSW, and certified trauma specialist and former Changing Tides coordinator for The Center for Hospice Care. D’Costa was one of the authors of the training manual. Now, she is the director of a consulting company, New Directions, in Chatham, NJ.
Changing Tides is a good approach to preventative mental health, says Grace Zambelli, PhD, a hospice consultant who co-wrote the manual and helped develop the program. Zambelli is also a licensed clinical psychologist and registered art therapist who works as a school psychologist for the Bernards Township Public Schools in Basking Ridge, NJ.
"I think a lot of times children are the least-noticed mourners," Zambelli says. While people are very concerned about the child’s grief right after the parent dies, they tend to forget the child might still be grieving months later, Zambelli adds. "Children may not show their grief because they may distract themselves with other things they need to do."
In addition, children continue to grow and change and progress toward maturity, all of which distracts them from grief, she explains.
The Changing Tides program received awards in 1995 and in 1996 for Excellence in Educational Programming from the National Hospice Organization in Arlington, VA.
The school’s window
Other hospices can develop their own school training programs or build one modeled after Changing Tides. Here’s what the program entails:
• Find an audience.
School professionals are a natural choice to teach about children’s bereavement. They see children more often than anyone else, except for parents. School teachers and staff can have a big impact on how well a child copes with a parent’s loss.
"We started doing the training three years ago, and the outcomes are that all of the schools we trained now are more aware and more comfortable responding to students who have a death of a family member or any death," D’Costa says. "Now, they’re able to implement a program for children in their schools," she adds.
Silent mourners
The first part of the Changing Tides manual includes background information about establishing a school-based group, including curriculum for a children’s group and for a parents’ group.
Typically, a hospice trainer would hold an educational program of four workshops for school guidance counselors, psychologists, social workers, nurses, and attendance counselors. While it would be ideal to also train teachers, it is not practical because of time constraints. The other school professionals, once trained, could set up training workshops or educational programs for teachers in their schools, D’Costa says.
• Teach children how to grieve.
"Children become our silent mourners because no one ever asks them, What do you miss about your dad?’ or even say, I heard your dad died over the summer, and I just wanted you to know that I’m so sorry,’" D’Costa says. "School professionals and teachers think the child looks fine, so let me just not upset him by saying anything.’" Children take their cue from adults and learn not to speak about their loved ones’ death.
Instead the child may begin to have problems with school work, or the child’s attention span may drop. These could be cues that the child is having problems and may need grief counseling.
Parents as advocates
Children do not go through the stages of grief in the same way that adults do, Zambelli notes. "Children may be sad one week and then fine for a couple of months," she says. "Then they might express rage, and then they might not."
Their grief may appear at a time when the child is the most vulnerable. For example, a child might have lost a father, then six months later a grandmother dies. The child’s grief may appear more readily after the grandmother’s death.
Hospices also can teach school professionals some basics about age-related understanding of death. For example, children at age four struggle with the idea that death is permanent. They may not understand that a person is never coming back again.
The idea of the permanence of death should gel when a child reaches age eight, yet even then children still have doubts. "I’ve had eight-year-old children who said, I knew he wasn’t coming back, but I really thought he went to live in another house,’" D’Costa says.
"Then the adults would say, I just feel so badly to think that my child would think her dad would go to live somewhere else,’" she adds. "But that’s just childlike thinking, and it’s not inconsistent because they are eight."
• Show how to be advocates for grieving children.
School professionals who have been through the Changing Tides program have a greater sensitivity and an organized way of reacting to children’s grief, D’Costa reports.
"When a teacher learns that a student has experienced a death in the family, then that teacher will refer the student to a psychologist or guidance counselor," she says.
Zambelli recalls a case where an eight-year-old girl lost her father, and felt very alone. "The family was upset the school didn’t respond in a way that they felt reassured the child."
The family also was unhappy that the school did not notify everyone involved with the child about her father’s death. "The school felt the student was given enough attention when she returned to class, and people did not respond positively," Zambelli says.
Once the child participated in a school-sponsored grief group, she received the support she needed from her peers and from her teacher. Also, the family felt better supported. "It helped normalize the loss for them a little bit," Zambelli says. "The group helped her to integrate that event in her life."
Also, parents need to be advocates for their grieving children, and they should make sure school officials know about the child’s grief, D’Costa says.
It’s especially important that teachers know about the child’s loss on holidays, such as Mother’s Day or Father’s Day, when the class might be making cards or presents for parents. This way, the teacher could suggest the child make a card for his or her deceased parent or for another relative. "There has to be a discussion with the child," D’Costa adds.
• Develop counseling sessions for children and parents.
Changing Tides provides handouts for parents and instructions for school officials on how to hold group support sessions for both children and their parents. The handouts include tips on how adults can help children cope with death. One handout has a checklist for parents, asking them to note any recent changes in their child’s behavior. (See Changing Tides sample handout, inserted in this issue.)
The program recommends dividing children into different age groups: ages 4 to 5 years; ages 6 to 8, ages 9 to 11, and ages 12 to 18. If a hospice is running the groups, there would be a volunteer and social worker in each group. If the school is running it, there should be school counselors, teachers, or other professionals there. The groups can meet for one hour a week, usually after school in the late afternoon or early evening.
While the children meet, their guardians could meet separately in their own group session.
The groups generally meet for 10 weeks. At the fifth week, the children have the night off, and the parents come in to meet with the person running their child’s group to receive information about their child’s progress and bereavement.
"Parents give us information, and we give them information about how we see the grieving process going," D’Costa says. For example, the group leader might tell the parents whether their children are able to discuss the death with other children.
"Also, we ask the parents if the group is serving the function they wanted for themselves," she adds.
That parent meeting is followed by four more regular sessions, and the last session again provides feedback to parents.
Getting children to talk
At the end of the 10 weeks, the parents, children, and school officials evaluate the program. They are asked:
• Did you notice any changes?
• Did you find that things were different?
• Was it helpful?
• What did you like? What did you not like?
The parents’ sessions are focused on parenting a grieving child. "They’ll bring up issues of their own grief, but for the most part, the focus is on children," D’Costa says.
• Use activities, as well as words.
With younger children, the group leaders often use drawing, crafts, magazines, scissors, and glue to help facilitate communication.
For example, the group leader might ask the children to make a collage that expresses their feelings about their loss and the change in their lives.
In one group, children cut out pictures of their parent’s favorite foods, the kinds of cars their parents drove, and pictures that illustrated their parents’ work.
"These were things that made this person who is no longer living come alive for the child," D’Costa says. "We get to know how this person fit into the child’s life and what the significance of the person was to the child."
For instance, a child might talk about his father’s favorite flavor of ice cream; and to this child, that is something the child misses.
Older groups of children and even teenagers also might like using crafts and collages as ways to express their grief. Hospices can teach school professionals how to start these activities.
[Editor’s note: The Center for Hospice Care sells its Changing Tides manual and video for $125, including shipping and handling. For more information on the child-parent bereavement program, you may contact the hospice at (973) 429-0300.]
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