How do you support a maternally grieving child/teen who comes to you for acute care?  For routine check ups?  For a physical ailment without a physical cause?  What do you say to them?  When a child or teen is not feeling well, most families will first reach out to their pediatrician, family doctor or other health care provider for a diagnosis and a cure.  For bereaved children and teens, they will experience pain that you can diagnose as grief related but that you can not cure or medicate. 

Grief is Painful - Mimi Mahon

Recognizing Grief

If you know that your patient's mother has died then you know your patient is bereaved:

• Acknowledge the mother's death even if your patient outwardly appears to be doing very well. This is important for all members of your practice. 
  
  • Hiding Grief - Mimi Mahon
• Sometimes health care providers don't know what to say or do and are afraid of saying or doing the wrong thing, so they don't say or do anything. Imagine this from your young patient's point of view, particularly if his/her mother was the one who usually brought him/her in for well and sick visits. The child/teen might think you don't know, that you don't care or that it is not a topic that you are supposed to talk about. These unintended negative messages can be avoided by simply acknowledging the death. You can say, "I know your mom died...how have you been feeling since she died?"
  
  • What to Say to A Grieving Child/Teen - Mimi Mahon
  • What to Say to A Grieving Child/Teen - Darcie Sims
  • How To Support a Grieving Child/Teen - Alexis D.
  • How to Support a Grieving Child/Teen - Laura Munts
  • What to Say to A Grieving Child/Teen - Darcie Sims
• Run through common stress symptoms - "How are you sleeping? Eating?"
• Find out when these symptoms occur - is there a pattern?

What if you do not know that a patient's mother has died?

What if you do not have any information about whether there has been a death in your patient's life?  How can you recognize grief? 

• ANY change (downward or upward) in behavior that you can not connect to a cause in your patient's life should prompt you to ask whether your patient has experienced a significant loss in their lives in the last couple of years.
• ANY unusual behavior (behaviors that you do not typically see in other patients in the same age/maturity range).
• ANY reference made by your patient to the death of someone they knew (family member, friend, neighbor, etc.).

Needing Additional Support 

Once you have determined that a patient is experiencing grief/bereavement responses, what do you do with this information?

• Know that your genuine caring presence, whether through your words or demeanor, may be very supportive. If a patient is hurting, even if you don't know the cause, let them know you are there and that you care.
• Some bereaved patients will have the resources they need to support them; others may need additional support. How do you determine whether your patient is exhibiting behaviors that indicate he/she may need additional support? See Is Additional Help Needed below.
• If you determine that additional help may be required, see Providing Bereavement Support Referrals below.

Is Additional Help Needed?

How can you tell whether the patient needs additional bereavement support services?

Warning Signs - Mimi Mahon

RED FLAGS - Signs that a grieving child/teen needs immediate help

Some behaviors in grieving children/teens are red flags, or emergencies.  Immediate help is needed if a patient is:

• Hurting himself
• Hurting someone else
• Damaging property

Hurting one's self or someone else includes:

• Self injury
• Having more "accidents" or getting hurt more than usual
• Saying that she wants to die
• Threatening to hurt someone else
• Treating other people badly, so much so that she is losing friends

If a patient is exhibiting any of these behaviors, immediately contact the patient's parent/guardian and be prepared to make bereavement support referrals. 

Click here for a list of on-line resources and bereavement support services for Delaware Valley.  Note that The Dougy Center web site, http://www.grievingchild.org/, lists child/teen bereavement support centers across the United States.

YELLOW FLAGS - Signs that a grieving child/teen might need more support

A yellow flag is just like a yellow light: it means caution.  Note that some of the Yellow Flags below may only be noticeable outside of a health care provider's office.  As a health care provider, you may, however, become aware of these Yellow Flags through what the patient's parent/guardian share with you.  Help may be needed if a child/teen:

• Asks for help: Child/teen indicates he wants additional help.
• Never speaks about the person who died: The child/teen chooses never to talk about the person who died, even when others bring it up. The child/teen perceives that she has no one with whom to speak.
• Expresses excessive anger: When someone dies, children/teens (and adults) often feel angry and/or frustrated. That's okay and healthy. Too much anger or frustration, however, can cause a child/teen to feel overwhelmed or out of control, and that can be unhealthy.
• Has physical symptoms that do not have an obvious physical cause: Children/teens who are grieving, like adults, might have physical symptoms, such as headaches or stomach aches. This is normal. If these symptoms persist, the child/teen's parent/guardian should be encouraged to take him to his health care provider. If nothing physical is found to be wrong, and the child/teen continues to have physical symptoms, the parent/guardian should be encourage to consider getting additional help.
• Significantly changes social interactions: Some children/teens do not interact with friends and family as they did before the death. A period of withdrawal is normal and healthy. If the withdrawal persists and the child/teen does not resume some activities outside of school, talk with her. This isolation may be a sign of needing additional help.
• Has dramatic changes in academic performance: Many children/teens' grades change during the year in which the death occurs. If the grade changes (downward or upward) continue into the following academic year, or other changes in performance continue for months, consider that the child/teen might benefit from more help. See Is overachieving below.
• Is overachieving: We tend not to recognize a dramatic increase in performance or participation as a sign of grief because it looks like things are "going well." Significant changes occur for a reason. It's important to try to understand the reasons for any dramatic change, regardless of whether it is perceived as positive or negative.
• Guilt: Almost all children/teens feel guilt or regret about something related to the death. "I didn't get to say goodbye." "We had a huge fight." Many children/teens need information about why the death was not their fault. Guilt is the one emotion it's important to ask about: "Most children feel guilt about something related to their mom's death. Do you?"
• Fear and worry: New fears often emerge after a death. A child/teen might be afraid that someone else will die, or worry that he will get sick, or be left alone. When fear and worry keep a child/teen from doing what she wants to do, she might benefit from other help.
• Anxiety: Most children/teens will be anxious after someone dies. For many, the anxiety decreases within months. For some, anxiety persists, causing behavioral changes, and might interfere with a child/teen's interactions with others.

Providing Bereavement Support Referrals 

Become an expert in bereavement support referrals.  If the child/teen is 12 years or older, then have a brochure or contact sheet to hand to them before they leave the examining room.  If your patient has symptoms that are grief related or if you make a bereavement support referral, follow up with the patient in a week or two, just like you do for other medical follow up. 

Become familiar with child/teen bereavement support in your area and on line.  Refer your patients and their families to these resources, including Mommy's Light's free Tradition Fulfillment_sm Services and Bereavement Education Materials.  To request copies of Mommy's Light's bereavement education materials, including our DVD "When a Mother Dies...Breaking Down the Walls of Silence," and our Warning Signs Brochure, click Request Information Form.

Click here for a list of on-line resources and bereavement support services for Delaware Valley.  Note that The Dougy Center web site, http://www.grievingchild.org/, lists child/teen bereavement support centers across the United States.

There are professionals who can help, including counselors, psychologists, psychiatrists and social workers.  Other health care providers or counselors may be able to provide you with referrals for professionals who specialize in childhood and teen bereavement.  Often the best referrals are from families who have benefited from bereavement counseling.  Share all the resources you know about with your patient directly, if age appropriate, and with the patient's family.
What to Look For in a Bereavement Professional - share this information with your patient's parent/guardian:

• Ask about the professional's specific education and experience with bereaved children and teens.
• Ask how many bereaved children/teens the professional has treated.
• Ask what format the bereavement support will take (group or individual) and how often and how long each session will run.

Any professional who tells or encourages a child/teen to "get over the death" or to "grow up" is unlikely to help a bereaved child/teen.