by Helga McClean

Bereavement care has become very much a part of life. Many adults benefit from the care and support they receive. However, it has only relatively recently been recognized, that children need support and help too. The question must be asked, how have families coped with bereaved children and above all, what can we do to help them?

When bereaved adults are asked if they have included their children in their bereavement they often say ?I have not told the children anything or 'I do not want to frighten them', etc. Very few people appreciate that this may be excluding the children.

To allow our children to grow up into happy well adjusted adults we have to allow them to discover their hopes and sorrows, help them to deal with them and the feelings which they may experience during bereavement. I agree with Virginia Axline who states that we should encourage children to discover, 'that the security of (their) world (is) not wholly outside (themselves) but that the stabilising centre (is) deep down inside that self.'

We as adults have to realize that children are aware what is going on. We have to take them seriously because the way we help our children during a period of loss and bereavement may not only have an effect on their mental health but also influence how they cope with future loss and bereavement.

Children can handle truth much better than they are given credit for by adults. Grollman said 'Remember - a person is a person no matter how small'. We need to give children the respect they deserve, listen to what they have to say and admit that we do not know all the answers. Often it is possible to qualify with a question, this will also give the adult the opportunity to assess how much the child knows and what his/her developmental level is, or indeed what his/her family tradition is. One four year old, who had lost his father, asked his mother what cremation was; when his mother hesitated with the answer he said , 'I think its just a quicker way to turn the body to ashes' - who can disagree with this?

When I was asked to set up a Bereavement Service in St. Andrew's Hospice a few years ago I was involved with a number of bereaved families. I felt that a group could be ideal to provide the right environment for children. It could encourage them to ask questions and their families might also be included. - At no time was it our intention to take away responsibility from families but to help them to cope with their own and their children's grief and possibly use the group as a reference point.

The aim was:-
- To give children a safe environment to express their feelings and emotions.
- To allow children to find answers to their questions and to provide them with information to help them make sense of the changes in their lives.
- To give children the opportunity to commemorate the person who has died by making memory boxes, collecting photographs, writing stories or letters, painting, drawing or having memory parties.
- To give children the opportunity to meet with other youngsters with similar experiences.
- To encourage them to share and compare, laugh and cry together, and above all give them permission to continue with life.
Who should counsel bereaved children?

I feel very strongly that counselling children should be left to people who have been trained in bereavement work with expertise in work with bereaved children. Children are very precious beings and deserve the best attention we can give them.

Peta Hemmings writes that a bereaved child has had to adapt to a world which has changed beyond recognition without the lost person.. 'it is our role as professionals ... to help the child to regain the joy and spontaneity of ... childhood. ... The resolution of bereavement lies in the child being able to maintain an awareness of its emotional impact. For children language is a difficult medium. ... Words are unreliable allies, cluttered with subtleties and double meanings. Play is a more natural language'. It helps a child to communicate effectively and it is the duty of adults to find the most effective type of play to help a child to regain some normality in life.

I very much believe that Groups can offer this opportunity. Groups are child centred and because a variety of play materials can be offered for a child to choose under expert supervision, he/she will be able to learn to communicate his feelings more effectively than if confronted solely with the spoken word. This would be inevitable if a counsellor, whose expertise was based on an adult model, spoke to a child and asked endless questions.

Robin, a ten year old boy who had lost both parents and was now being looked after by his grandmother said 'I don't like being asked "how do you feel?" every time the lady (the counsellor) comes to see me. In the group I only need to speak when I want to.'

I also remember three year old Lizzy, whose parents spoke to her in great detail about her father dying, they even prepared her for her father?s burial even before he had died - far too much for her young mind to digest. She used to be a placid and contented child who, apparently suddenly turned into a very unhappy and angry little girl. She came to the Drop-In and the Educational Psychologist, who helped with the setting up of the Drop-In and who visited regularly, gently guided her towards the sand tray. Lizzy buried small plastic animals in the sand and then very angrily dug them out again. Her message was obvious to those who could understand her and those who were listening - namely, allow a child to go at her own pace and do not assume that her cognitive ability is the same as that of an adult. Her parents then treated her as they used to, as a very bright 3 year old and not as their equal. In their own grief, they had forgotten this.

Children need their questions answered in an appropriate way. They need to be listened to and be taken seriously. Limited vocabulary does not mean a child has no feelings but neither does it mean a child understands everything we say even if he/she is articulate and bright beyond his/her years.

A two year old twin was crying for his Grandpa. He had not been told that he had died, although he and his twin sister had been involved in the caring for Grandpa at home and later visited him in the Hospital and the Hospice. He and his sister started coming to the Drop-In and eventually he came to terms with the reality that grandpa was not coming back. Both children were bright and articulate and asked questions when we read stories or when the other children spoke about the people they had lost. The little girl seemed very supportive to her brother but never appeared to display any feelings of sadness or anger. - Too often children feel responsible for others. However, one day in the middle of play she asked her mother if she was permitted to feel sad as well. Her mother gave her permission and told her that she missed Grandpa as well. The child appeared happy with this and continued with her play. - Perhaps children need permission to express their deeper feelings.

Why Group Work ?

Children spend their lives in groups, they go to nursery and school and some may go to Sunday school, Brownies or Cubs. They appear to find '...the together situation more stimulating than adults' Davis goes on to say that 'the mere presence of others represents a source of comfort or support in the face of anxiety ...'. Bereaved Children often find themselves very isolated and vulnerable because they very rarely find anyone in similar situations at school or in any of the social groups they attend. Bereaved children are often bullied in school and because of this suffer loss of confidence and sometimes this leads to school refusal. They are unable to cope with the strength of their own feelings after a bereavement as well as the isolation from their peers. Not all school children have experienced a death in their family and as schools are notoriously poor at including issues of loss and death in their curriculum, bereaved children are seen as difficult and different. Teachers too have difficulties supporting bereaved children because this not part of their training. However, the Education Authorities are becoming more and more aware of this issue and are now starting to include the subject in in-service - and general teacher training.

A group, under appropriate guidance, can help to address all these issues and give children some sense of belonging. A group member can get substantial support by observing others and learn that his/her own behaviour is not unusual. Davis states that 'the presence of others may provide substantial information, whether this be clues about the way the forthcoming task is to be approached or cues as to the appropriate behaviour to be exhibited.'

These were my thoughts when I brought a proposal to the Hospice Matron who then agreed that we should have a mixed group of Bereaved and Pre-Bereaved Children, meaning, children who were visiting the Hospice. It was hoped to give the visiting children some support to enable them to cope with the forthcoming death of a loved one, and to let them have a good experience by coming to the playroom in the Hospice. There was some resistance to forming such a group, the argument was, that it might frighten visiting children to be in the same group of children who would communicate freely with each other about their bereavements. However, I discussed this with an educational psychologist, who came to the Hospice to give a lecture on 'Childhood Bereavement'. She gave me a lot of encouragement and support, as did the Matron of the Hospice. So we set about to start a Drop-In for Bereaved and Pre-Bereaved Children.

Volunteers

We recruited volunteers, mainly from within the Hospice. We devised our own training programme and felt very positive about our venture. However, we knew what the volunteers' role was supposed to be; we wanted them to supervise the children, play with them, make sure they were safe and stayed within the playroom. We also assumed that everything that happened within the group was confidential. Nevertheless, initially this was apparently not communicated adequately, as we found out that two volunteers discussed one of our children in a public place. The volunteers had to be told exactly what they were required to do and what their conduct should be to protect them and the children in their care. Each volunteer was therefore issued with a 'Code of Conduct'.

Open Group

The Drop-In was not only a group for Bereaved and Pre-Bereaved Children but also an open group. In a way a group without a beginning and without an ending, we were hoping that this would give the children more control. They could come and go when they felt they had enough and not because a program was running for a certain number of weeks. This made planning very difficult, however, it also created a challenge for the leaders as every group session was different and we always had to be aware of potential difficulties, like older children getting bored and new children needing a lot of attention.
Play Sessions

The play sessions were held once a week for 1½ hours. We usually planned a central activity, to settle the children and to capture their interest and their imagination. Some of the activities we used were - making things like posters for display and cards for special occasions. The older children sometimes were involved in a special project, like making space ships etc. Sometimes the children did some gardening and the idea was that this should hopefully help them to understand the changes in nature and life. Other activities included the use of play-dough, sand play, memory boxes, artwork, quiet times, involvement of friends and memorial parties.

Occasionally, when the children were particularly boisterous, I would ask them to make up rules. I suggested that even though they were special children they too had to follow rules. The children then would write rules with coloured marker pens on a big white board. Most of them were keen to take part in this and the outcome was always remarkable. They all knew very well what had happened; of course they had to find their boundaries and were testing us to find out how far we would allow them to go.

I feel very strongly that bereaved children should be aware of their boundaries in order to allow them to integrate into 'normal' life again. People often make special allowances for bereaved children, they spoil them and grant them every wish. Often children are showered with presents to give them some comfort after a loss. This is a habit which is very difficult to reverse. Children will expect to be treated as special and this can often cause discord in the family.

Billy

In spite of all the concerns the group worked very well and this became evident very early on. Billy appeared at the playroom door one day with his mother, they had been visiting Billy's father who had just been admitted to the Hospice . Billy was a very bright and lively nine year old who was very close to his father. The father had great insight and communicated with the boy really well. We encouraged him and his parents to use the work book , 'When someone special has a very serious illness' . We also encouraged the father to write to his son and to talk to him about the future without him. The youngster often used to sit on his father's bed and the two were in deep conversation. - Then one day during a group session a call came through to say that Billy's father was dying and could we keep the boy until his mother was ready to collect him. I called all the children together and read 'The Water Bugs and the Dragon Flies'. When I looked up from the book I noticed that all the children were sitting around Billy as if they were protecting him. - I knew then that the group was working for both categories of children. This was giving us a good vehicle to do justice to the needs of both bereaved and pre-bereaved children. We were quite sure before that the Drop-In would work for bereaved youngsters but were unsure how we could cope with the needs of both together. Elizabeth Kubler-Ross, who has probably more experience in this field than anyone else said: - 'The most meaningful help that we can give any relative - child or adult - is to share his feelings before the event of death and allow him to work through his feelings, whether they are rational or irrational'.

Feelings

Feelings are part of us, whether we are children or adults. They are constantly with us, even if we are not aware of them and are a natural response to whatever is happening to us in life. If we are injured we feel hurt, if we are bereaved we feel depressed, sad or angry and if we are safe we feel content. Sometimes things move so fast that we do not recognize our feelings, or sometimes our pain is too great so we suppress our feelings in order to continue with our lives. We as adults find it difficult to cope with this confusion, so what do children do? What chance do they have if no one is willing to listen to them?

We can help children to understand that we all need feelings. Only by allowing feelings to come out can our bodies and minds heal and our lives be rebuild. Often, when feelings are repressed there is only numbness because we are afraid of the consequences. We are afraid that feelings of grief may be unbearable and that we may not be able to cope with the pain of our memories. However, if we suppress sad memories we also suppress the happy ones. Children cannot see the signs as adults do, they are often frightened if their behaviour changes. Sometimes boredom and depression cover anger and hopelessness.

Children need a lot of help before they can express their feelings, but if this is possible it will help to transform their lives. They will gain self respect and confidence and above all regain some control over their lives.

We sometimes read a lovely story called 'A Huge Bag of Worries'. This story illustrates very well how children can take on the worries of the world and then get so overwhelmed that they are frightened to allow any of these worries out of the bag. However, when the bag is finally opened by a caring adult, most of the worries do not even belong to the child.

It makes it easier and certainly less scary for a child if an adult, who he or she feels safe with and trusts helps to disperse all the scary feelings. Open the bag and allow these worries out and give the child permission to live a happy life.

Sometimes we would address feelings by giving the children a drawing of a small body and ask them to draw in their feelings with different colours or use different materials like wool or different colours of shredded paper, sequence, glitter, sticky shapes etc.

Anger

One day a bereaved child said to me 'Why do I feel so angry, I have never felt like this before, I am frightened'.

Anger is probably one of the feelings we as adults find most difficult to cope with in children because of the many ways it manifests. .Anger is an emotion which is very closely associated with fear, and the way adults deal with this very often depends on past experience. Where he/she has come from and the way he/she has been brought up. Children do not have these experiences. They sometimes punish a close person, because they are blaming this person for the death of their loved one. This normal and basic reaction to separation may be carried through to adult life and be expected following bereavement. Other frequent feelings may be a general irritability and bitterness, restlessness and tension, largely because the world has become an insecure or dangerous place.

Sometimes anger can be so frightening because the reality of loss is considered as a major threat. Bereavement undermines confidence and to be able to blame someone, even oneself, means it is less disturbing than accepting that life is uncertain. To blame someone or to find some explanation to help evade or deny death is the individual's way to gain some control over the tragedy in his/her life. The Drop-In provided a safe and controlled environment to help and encourage children to get rid of this uncomfortable emotional baggage and to gain some kind of control.

Conclusion

The needs of bereaved children and of children who have to deal with serious illness in a significant person in their lives are becoming more recognized now. Nevertheless, too many models on working with these children are still based on adult counselling. However, although children experience many feelings akin to adult bereavement and loss, they should not be expected to conform to a set pattern but be allowed to set their own pace. Only safe, secure and loving environment can make this possible. This should of course be the home but if this is not possible a group for children, like the Drop-In in St. Andrew's Hospice, is the ideal situation. It gives children the space and support they need and carers the opportunity to participate and learn how to support their children. Families have the opportunity to heal together and to look forward to a healthy and happy future.