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8 Strategies for Working with Grieving Children
10 CEUs 8 Strategies for Working with Grieving Children

Manual of Articles Sections 15 - 28
Section 15
Childhood Mourning: Case Study of Multiple Losses

Question 15 | Answer Booklet | Table of Contents | Grief CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, MFT CEU

Bereavement in childhood is not expressed in the same manner common to adults and is related to the child’s developmental state; but that does not mean that it is any less painful and potentially pathological (Black, 1998;mourning children Grief Strategies for Working with Grieving  social work continuing ed Shultz, 1999). By age five, the child can appreciate that death is permanent (Black, 1998). Grief and bereavement have immediate and long-lasting consequences (Black, 1996; Dowdney et al., 1999; Luecken, 2000). Child and adolescent bereavement often results in depression, anxiety, and behavioral disturbances (Christ, Siegel, & Christ, 2002; Dowdney, 2000; Sanchez, Fristad, Weller, Weller, & Moye, 1994; E. Weller, Weller, Fristad, & Bowes, 1990; R. Weller, Weller, Fristad, & Bowes 1991). In one study, 37% of children suffered major depressive disorder one year after bereavement (R. Weller et al., 1991). In bereaved children, childhood psychiatric disorders are increased five-fold when compared to the general population (Rutter, 1966). The expression of grief has been correlated to improved functional status (Kranzler, Shaffer, Wasserman, & Davies, 1990).

Further, unresolved childhood grief and perception of vulnerability to loss result in impaired adult relationships and increased adult psychopathology (Edmans & Marcellino-Boisvert, 2002; Mireault & Bond, 1992). Early parental loss through death or permanent separation is statistically associated with vulnerability to major adult psychiatric illnesses (Agid et al., 1999). An anthropologic study suggests that the loss of the maternal grandmother is associated with decreased lifespan of the child (Jamison, Cornell, Jamison, & Nakazato, 2002). This study is of increasing significance in our modern society wherein both parents work and the role of caregiver often reverts to the grandparents (Fuller-Thomson & Minkler, 2001).

Though bereavement in childhood is critical and its role in later psychopathology quite significant, there is still relatively limited research and that which has been studied is most often related to death of parent or sibling (Agid et al., 1999; Black, 1998; Cerel, Fristad, Weller, & Weller, 1999; Christ et al., 2002; Dowdney, 2000; Dowdney et al., 1999; Kranzler et al., 1990; Luecken, 2000; Mireault & Bond, 1992; Sanchez et al., 1994; Thompson et al., 1998; Tweed, Schoenbach, George, & Blazer, 1989; E. Weller et al., 1990; R. Weller et al., 1991). There is minimal research associated with childhood bereavement and the death of grandparents, though one study supports lower functioning of adolescents admitted to a psychiatric facility when there is grandparent death during infancy or when the patient’s mother severely reacted to the grandparent’s death (Yates et al., 1989). A body of literature addresses multiple catastrophic losses and traumatic events in childhood and adolescence; however, no literature addresses the multiple losses that can occur within an aging family and how the bereaved child should best cope with such (Bolton, O’Ryan, Udwin, Boyle, & Yule, 2000; Laor et al., 2002; Papageorgiou et al., 2000; Pfefferbaum et al., 2000; Winje & Ulvik, 1998).

Specifically, multiple losses within short periods of time make one question life and can exponentially influence one’s coping skills. But what are the effects on a child and what should be done when the next loss occurs? In this unusual case, a 7-year-old boy bereaved the loss of five significant relatives within 18 months in the context of being born to older parents.

Case
The child was born on 7-10-95 to a 47-year-old psychiatrist father and a 45-year-old business executive mother. Though the father had four children from a prior marriage, the mother had no children from her former marriage. The mother’s previous OB-GYN work-up was consistent with stenosed fallopian tubes. Thus this child was very much a welcomed surprise. Though the father had a thriving private practice, a mutual determination was for a 3,000-mile relocation to be near family. Both parents felt that it would be significant for the child’s development to be near the paternal grandparents, especially the grandmother, and other family relatives.

Bubby Becky
The child’s paternal grandmother died at age 79 (11-13-01) in a tragic motor vehicle accident. She had been a very caring grandmother and had often visited with the child, either at her home or the home of the child. Frequently this retired school teacher would bring books; the child’s common complaint before her visits was ‘‘Oh no! Bubby Becky is coming and she is going to give me a book and not a toy for my birthday.’’ Nevertheless, they reveled in each other’s love for a precious 6 years. When she was killed, his first comment was ‘‘I am angry at Bubby Becky for dying and going to heaven before I could have one last hug.’’ He was present for the eulogy and shiva, but was not present at the graveside funeral. Over the weeks and months following her death, positive memories were discussed with his parents, he was encouraged to verbalize his feelings, and at the child’s request the family went to the beach where he had had seaweed fights with his Bubby. No changes in school work or school behaviors were noted, though intermittent sadness replaced the original anger and resolved over the course of several months. At the tombstone unveiling 11 months later, he was the youngest and only grandchild of six who spoke and summarized the feelings of all: ‘‘Bubby Becky will never die for there is a piece of her in my heart forever.’’ Of note, he was very supportive of his paternal grandfather.

Grandma Doris
The child’s maternal grandmother died at age 81 (7-31-02) from an MI. Due to distance, there had been infrequent visits; but he commented on how much she must have loved him and how he would miss her. His first response when told of her death was ‘‘Oh why do they have to die this way? Grandma Doris got sick and died. Bubby died painfully! Mom, I want you to die peacefully.’’ He was very sensitive to his mother’s grief. He attended the memorial service and made for his maternal grandmother a multicolored perla-bead heart—‘‘green, her favorite color and heart warming; orange for soul; red representing blood and heart; and yellow for guts.’’

Papa Jerry
His paternal grandfather died at the age of 87 (5-21-03) following extended hospitalizations associated with a ruptured abdominal aortic aneurysm. When the grandfather was hospitalized post-surgery, the father discussed in detail with his son the illness, the surgery, the difficulties that would exist in the grandfather getting better, and the possibility that he would die. Emphasis was placed on the fact that the child was angry that he could not speak to Bubby Becky and therefore the parents wanted him to come to the ICU to speak to his Papa Jerry. The son had previously done rounds with the father and was used to seeing heart monitors, IV tubing, and ventilators but not comatose patients. Prior to entering the ICU, the father explained what the son would see and explained how all of the multiple tubes and sedation served a purpose in helping to stabilize the grandfather. The child was made to realize that this was his chance to say anything he ever wanted to say to his grandfather about everything that they had ever done together, whatever was interesting to the child that he thought the grandfather would want to hear, and in general be able to share loving thoughts. The child saw his grandfather on multiple occasions in the first ICU and then in another when he was transferred to the hospital where the father was an attending.

Though the grandfather was in a non-responsive state, the child was able to verbalize many feelings and thoughts not only about Papa Jerry but also about Bubby Becky. Sadness was an intermittent feeling expressed as well as caring for his father. At one point, he told his mother, ‘‘This doesn’t look too good; Daddy may soon be an orphan.’’ When the grandfather improved, and was able to talk, brightness was noted in the child—he playfully talked to his now communicative grandfather and showed relief regarding his father’s plight. After a brief time in a rehabilitation facility, the grandfather regressed, required hospitalization, had a respiratory arrest with re-intubation, and was found to have a dissected thoracic aortic aneurysm. At this juncture, the child desired to learn medically what had occurred and the parents utilized the mayoclinic.com website to review with the child aneurysms. He appeared relieved to understand the illness process and it made it possible for him to understand that his paternal grandfather would die shortly. At the eulogy, the child again spoke and eloquently read from his hand written card with his penciled rose:

‘‘Too many petals and thorns have fallen from the family tree.’’ And at the graveside funeral, he requested and shoveled earth onto the coffin.

Uncle Richard
His maternal uncle died at the age of 49 (5-24-03) from an MI in the midst of a pharmaceutical clinical trial. The suddenness of this death immediately following the recent death of the paternal grandfather was a shock to the child. He had not seen his uncle often, but realized that this uncle was very precious to his mother. Also, he did not understand why a young man had died. However, when longstanding diabetes was explained with potential complications, the child felt relieved to again learn there was a cause.

To the parents, this was a difficult death, for they were both older than the deceased and suddenly realized that the child would question his vulnerability. In the process of packing for a trip for the memorial service, the child began to revisit issues involving his paternal grandparents. He focused on wanting to return to Roosevelt Beach where the seaweed fights were as remembrance:

‘‘We could go there in the future. The beach will always be our place to remember both Bubby Becky and Papa Jerry.’’ Just before the trip, the family learned of the fifth loss—Uncle Richard’s mother-in-law, who had no noted illnesses, had died from a burst cerebral aneurysm (5-31-03). As such, the memorial service had the burden of two deaths. This child was the only cousin= niece=nephew to actually speak at the uncle’s eulogy where over 200 persons were in attendance. He commented ‘‘Richard I did not know you well or see you often, but I hope you are happy with your mom. Richard you are my uncle and will be my uncle forever.’’

Aftermath to the Five Deaths
When he arrived home after the last memorial service (6-2-03), the child began to discuss the suddenness of death:

a) ‘‘I can visualize the blood stopping in the heart.’’
b) ‘‘When someone dies my heart misses a beat’’ (and he counted out beats and missed one).
c) ‘‘Can someone die at 8 or 10?’’
d) He asked his mother ‘‘Did your grandparents die suddenly?’’
e) He discussed how he had wished for the 5 deceased people to come back and when he thought of Papa Jerry being ill and in pain near his death, he commented: ‘‘I want them to come back healthy.’’
f) Then he asked the father how many jobs could he do at the same time. He wanted to be a gymnast, chemist and heart doctor; a gymnast to keep in shape and not get ill, a chemist like his father and paternal grandfather, and a heart doctor to keep people from dying.
g) Finally he addressed the five deaths and commented: ‘‘Of all of five, three were ill and two died suddenly.’’

And this suddenness appeared to be the key: he was able to accept the first four deaths due to age and illness, but when the fifth died suddenly he went into thoughts regarding suddenness of death and whether it would affect him=his parents=others and even what career he should aspire to in order to prevent such death. Then he had dreams wherein everyone in the family died from a CVA or MI and then they were killed a second and a third time and finally they went into a black heaven (abyss) in which they were truly dead. He continued to relive different aspects of each death and finally asked when Uncle Richard developed diabetes; when told 8, he was frightened.

The parents continued to encourage his verbalization and writings and discussed emotions and illnesses openly while emphasizing his health and the health of his parents. With time, the child was not overtly sad and instead he focused on positive activities with his parents and positive memories of the deceased. Though the child did not make as many overt statements regarding death, grief, and loss as he had before, his writings continued and were very significant.
- Kaufman, Kenneth & Nathanial Kaufman; Childhood mourning; prospective case analysis of multiple losses; Death Studies; Apr 2005; Vol. 29; Issue 3.
The article above contains foundational information. Articles below contain optional updates.


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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about a case study of multiple losses in childhood mourning. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 15
According to Kaufman & Kaufman, what is the result of unresolved childhood grief and perception of vulnerability to loss? Record the letter of the correct answer the Answer Booklet.

 
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The article above contains foundational information. Articles below contain optional updates.
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