ARTICLE

Using Creative Activities as Intervention for Grieving Children
Cathy A. Malchiodi

This article is reprinted from TLC's Journal, TRAUMA AND LOSS: Research and Interventions, Volume 3, Number 1, 2003

Cathy A. Malchiodi, LPCC, LPAT, is the Editor of Trauma and Loss: Research and Interventions and the author of numerous books on art therapy, including Handbook of Art Therapy (Guilford, 2003), Understanding of Children’s Drawings (Guilford, 1998), and The Art Therapy Sourcebook (McGraw Hill, 1998). She is also the co-author of Helping Children Feel Safe (William Steele, Cathy Malchiodi, and Nancy Klein) published by the National Institute for Trauma and Loss in Children in 2002. She is on the Board of Directors of the American Art Therapy Association and has given more than invited 170 presentations and keynotes on the use of art as an intervention with children, adults, and families experiencing trauma, abuse, violence, or loss.

Abstract: Exposure to the death of a loved one—whether a parent, sibling, or family pet-- is a painful experience for children and usually requires intervention to explore and facilitate expression of feelings and questions about loss and tragedy. Drawing is one activity that can help both the trauma specialist and children who are grieving a death identify feelings and understand loss through sensory means. This article discusses how children perceive death at various ages and stages, how sudden traumatic death impacts children, and how drawing and creative activities can be important in work with children who experience the loss of a parent or loved one.

Children’s Expression of Grief
The National Association of School Psychologists (2001) summarizes the range of children’s grief reactions as follows:

• Emotional shock-- Children may have a noticeable lack of affect, appear numb, lack reaction to events, or seem depersonalized. This behavior may serve as way to detach from the pain of moment or memories of loss.

• Regressive behaviors – Children may suddenly need to sleep in a parent’s bed or may have difficulty separating from parents, family members, or caretakers, or may need to be held or rocked.

• Repetitious behavior– Children may repeat play activities or themes or stories in their drawings. They also may repeatedly ask the same questions because a death has been hard to believe or accept; these questions, however, can help to identify any misinformation the child may have about the event.

• Sudden mood swings or unusual behavior– Children may suddenly seem irritable, frustrated, fearful, or helpless, reflections of their internal feelings and their need to find control over a situation they have little control.

Webb (2002) notes that the following aspects “differentiate” children’s grief from that of adults:

1. "Children’s immature cognitive development interferes with their understanding about the irreversibility, universality, and inevitability of death.
2. Children have a limited capacity to tolerate emotional pain.
3. Children have limited ability to verbalize their feelings.
4. Children are sensitive about ‘being different’ from their peers.
5. Children are able to express their feelings in play therapy.” (p. 14)

Children’s Understanding of Death
Adults sometimes assume that children have little or no comprehension of death or dying and therefore believe that it is not important to talk with children about their feelings and beliefs about death. While children of various ages and stages understand death and loss in different ways, all children do understand death in specific ways, dependent on their age and personal experiences. The following brief section describes general developmental stages in children’s understanding of death and dying, beginning with very young children. Jean Piaget’s stages of development, familiar to those who work in mental health and educational settings, are used as a foundation for this discussion.

Young Children
Children from the ages of 2 to 7 years fall into Piaget’s preoperational stage, a time when children begin to represent their world with words, images, drawings, and imaginative play activities. Children tend to be egocentric, seeing the world as revolving around them and thus may not differentiate between thoughts and deeds. When a relative dies, a child may believe that she caused the death through her own anger or wishes.

In my experience in working with children who have lost a parent, grandparent, or sibling, magical thinking common at this age effects how they perceive the dead person and their possible role in the death. For example, a 5-year-old boy I worked with several years ago was in a car accident in which his older brother was killed on impact; the 5-year-old only sustained minor physical injury. For weeks following the event, the boy reported that a “ghost” was present in his bedroom each night and that this ghost wanted to take him to where his dead brother was. In one of the sessions the boy expressed his fears that he had caused his brother’s death; a few days before the accident, the boy and his brother had a fight and the 5-year-old, in a moment of anger, wished that something bad would happen to his brother. When his brother died in the accident and he did not, the boy blamed himself for the death. In similar cases, children may feel guilt about a dead parent they have disobeyed; they also may believe that the person died because of his or her own bad or careless actions or deeds.

Children at this age also do not comprehend that death is irreversible and think that the person can be brought back to life by their own actions or the actions of another, such as a parent or doctor. Seeing a body in a casket may not be understood and the child may believe that the deceased can still feel, engage in activities, or may just be sleeping. Children may ask if the person will be able to breathe when placed under ground or if the individual will be afraid of the dark when buried; these observations reflect the child’s own egocentricity in relating to the dead person from his or her own perspective. Thinking is literal and non-logical and may be distorted to fit the child’s idiosyncrasies.

Many have debated whether or not young children are capable of mourning a death. Some believe that one must have mature awareness of death to do so, while others, like Bowlby (1960) feel that mourning is possible in young children. In other words, because young children have object constancy and react with strong emotions to the absence or loss of a meaningful person, this may be considered mourning. In contrast, it can be argued that because young children do not understand the finality or significance of death, mourning is not truly occurring, but may instead be called “grief reactions” (Webb, 2001).

Elementary School Age Children
Children from ages 7 to 11 years fall into Piaget’s stage of concrete operations. During this stage there is reduced egocentricity and an improved capacity for reasoning. Children develop organizational skills, learn to read, and to use language more proficiently, signaling their developing cognitive abilities. These abilities to write, read, and comprehend allow children to think more deeply about the differences between life and death. During this period of development children do realize that death is irreversible, and begin to understand that death is inevitable, and that it is a universal experience (that we all will die someday). Despite knowing the latter, however, most children still find it difficult to believe that death will happen to them in the future; children generally feel that death is something that happens to older people, unless they have had an experience to the contrary. For most children, death is a remote and distant expectation, but it is something that can be conceptualized at this age.

Children in elementary school may have a variety of well-developed ideas about the deceased. In the earlier part of this stage, children talk about skeletons, ghosts, or other entities that the dead take on after life. In other words, death is not completely finalized, but can assume various forms. Later, at age 9 or 10, children develop a more realistic perception, knowing that the dead person is buried in the cemetery; they may also express wishes to talk to the deceased in heaven or some other place depending on their religious beliefs.

Older Children
From the ages of 11 to 15 years children are in Piaget’s formal operational stage and enter a more mature time of thought and understanding. Their thinking becomes more logical, they are able to handle several variables at once, and they are capable of handling abstract ideas. Formal operational individuals are more systematic in problem solving and can use deductive thinking to test and understand why things happen. Hence, children and adolescents can now imagine ideas that may be abstract and can reason logically about them. Because the idea of death encompasses not only a physical, tangible process, but also abstract and less tangible elements relating to spiritual and religious concepts, individuals have more cognitive resources to aid in their understanding.

Drawings have proven to be a good reflection of children’s abilities to conceptualize death in abstract terms. Lonetto (1980) studied children’s drawings at different ages and found a shift to the representing death in abstract terms among 12-year-olds. They portrayed death with black crayon designs, describing black as representing “darkness.” Lonetto found that children at this age seem to not only perceive death as a biological inevitability and as universal, they also have an appreciation for abstract concepts related to death.

Finally, although individuals at this age can comprehend and understand death, one’s own death is still not truly seen as a possibility. Adolescents, for example, can think about death in philosophical and abstract terms and can discuss it in detail, yet many do not see their own behaviors as putting themselves in danger of death (from drug use or reckless driving). However, when confronted with actual experiences of death, such as death of a classmate or family member, death does seem to become a more realistic possibility. In an experience I had working in two schools where fatal shootings took place, adolescents expressed a greater fear about their own mortality and a greater understanding that death can come about at any age.

Sudden, Traumatic Death
The grief process under normal circumstances is difficult; it is often more intense if a sudden, traumatic death is experienced. If the death is the result of a homicide (domestic or interpersonal violence or criminal activity) or suicide, the situation may be complicated by a legal inquiry, interactions with law enforcement, and sensational or even inaccurate coverage by law enforcement. Repeated contact with various agencies and individuals involved in the investigation may deepen the sorrow, confusion, and suffering of survivors, particularly children who may be trying to make sense of what has happened.

Death resulting from sudden and terminal physical illnesses may also be more intense than those in which survivors had time to prepare for grief. For example, I recently worked with two young children who lost their father due to pancreatic cancer, an illness that strikes suddenly and often without much warning. Because it is difficult to diagnose at an early stage, death often occurs within months and families have little time to prepare for their loss. When I met with the children they were still in deep shock about their father’s sudden death and could not understand how he could be healthy enough to play with them only weeks before he died. Their mother was in a similar state of shock, finding it impossible to even believe that her husband was now dead and that she had to care for her children without him. Both mother and children felt like his death was a random act of violence, similar to a homicide or accidental death that comes without much warning.

Grief after a sudden, traumatic death can predispose a child to complicated grieving that can lead to posttraumatic stress disorder (PTSD). These children are particularly at risk for depression, psychosomatic problems, difficulties in school, and suicide attempts.

Using Creative Activities as Intervention
Drawing and other creative activities are versatile and effective modalities for evaluation of and intervention with children who have experienced loss, particularly loss associated with traumatic events. Children usually do not have the words to articulate their feelings and perceptions about death, but sensory activities such as drawing and other art activities are a natural language through which to express their trauma and grief (Gil, 1991). Children’s drawings and art expressions provide a way for us to witness their reactions, experiences, and perceptions of death. Trauma specialists can enhance intervention with children who have experienced significant loss through the imaginative world of symbols and picture making. It is a child-appropriate way for trauma specialists to begin to understand the depths of their suffering and assist children through what will be a painful and likely extended process of recovery.

Drawing is particularly effective with those children who can make recognizable drawings of people, animals, houses, tree, and other aspects of their environment. It may also be useful with younger children who still make scribbles, but can tell stories about their creations. The process of drawing provides a catalyst for discussion and an opportunity for trauma specialists to support and guide self-expression. The creative expressions of children can literally “illustrate” to us their fears, adaptive coping skills, and beliefs about death and dying. They offer an avenue of information to help us formulate future intervention and recognize more serious grief responses.

The experience of the death of a loved one or significant friend or schoolmate will be slightly different for each child, but there are a variety of activities that can be used or adapted with most children, particularly school-age children. Many of the following activities are more fully described in Helping Children Feel Safe (Steele, Malchiodi, & Klein, 2002), but are summarized below:

• What’s your worry? Therapists and counselors who use drawing with traumatized children often ask them to draw their feelings, especially their worries and fears. Encouraging children to draw their feelings initiates the flow of sensory memories related to what are often overwhelming emotions associated with a specific trauma. For example, you might ask a child to show you through using color, line, shape, or figures in a drawing “what your worry looks like,” or “what makes you afraid since [the loss of a parent, the death of your dog] happened.”

• Transform your worry. A simple drawing of something such as “worry” can be used to help the child transform what is worrisome into something less troublesome or frightening. For example, I might say, “What colors, shapes, or lines would help that worry ‘feel better?’ Try drawing that color or shape on the same page as your worry in a way that could help your worry feel better.” Or, ”If you had a special pretend friend who could help you with your fear, what would he or she look like? Imagine a special person or even a magic animal that would help you feel better.”

• Magic Book. This activity is also helps to empower children to find their own solutions to worries and fears. “Imagine you have a magic book (see activity sheet in Helping Children Feel Safe) that knows the answers to your problems and worries. When you talk to your magic book it is always a good listener and if you are patient, it always comes up with an answer. Ask the child to color it anyway he or she wants and then suggest, “Try asking your magic book a question about a problem you are having.” If a child gets stuck on this part of the activity, I might ask the child to draw the problem or worry he or she is having and I also suggest that we can work together to get an answer from the magic book.

• My “Safe Box.” Often a child recovering from a traumatic loss needs to find ways to feel safe and secure. I encourage children to work with me to create a “safe box” in which they can put a variety of objects and photos that help them to feel protected and reduce their feelings of worry. A simple shoebox can be used as a container to be decorated with magazine and photo images that the child enjoys looking at and finds comforting; special objects such as toys, mementos, and personal photographs can be placed inside the box. Creating a “safe place” in the form of a collage is a variation of this activity. A piece of poster board or cardboard can serve as the background for photo images that reduce worry and fear and help the child to feel peaceful and calm during difficult moments.

• Memory Box. For some children, creating a memory box may be appropriate, especially if worries and fears have been addressed. Any small box can be used as a symbolic container for “memories”—objects made of clay that represent people or events, small drawings of good times with the deceased person, photos of family, or small mementos that remind the child of positive experiences with the dead person.

Guidelines for Helping Children Cope with Traumatic Death
Trauma specialists using drawing, play, and other activities with children who are confronted with traumatic death need to be aware of the following:

• Allow children to be the “experts” about their art expressions and about their experiences. This allows the child to feel empowered through telling you the story of “what happened,” recalling memories, and defining feels. It is important for trauma specialists to convey to children that they appreciate their expertise as well as courage in being able to share their experiences through drawing and talking about their loss. Identifying children as “experts” also allows helping professionals to be less anxious about knowing all the answers when it comes to traumatic death.

• Assume that all children of all ages want and need to understand death. Sometimes trauma specialists shy away from discussing death, believing that children do not want or cannot understand the concept. However, it is important to give children information at the level they can understand. Use creative activities to explore their conceptualization about death.

• Make sure that parents and families understand that their children may need further intervention in the months and years to come. Additional help may be necessary if children experience additional traumas or loss or when they reach a developmental milestone (such as becoming an adolescent).

• Understand your own feelings about death, especially those associated with traumatic loss. All trauma specialists may struggle with making sense of the lives lost on September 11th, 2001. It is those deaths that are the result of what seem like random acts of violence that are the most important to find meaning and answers. Make sure you understand your own perceptions and beliefs before you begin work with children who have experienced traumatic loss.

Conclusion
Working with children who have experienced traumatic loss is not an easy task, even under the best of circumstances. Fortunately, creative activities such as drawing provide children with a natural way to explore and express themselves, especially when words are inadequate. For trauma specialists, these activities can offer both a way to understand children who are grieving a loss as well as creatively empower them in their journey to recovery.mu

References
Bowlby, J. (1960) Grief and mourning in infancy and early childhood. Psychoanalytic Study of the Child, 15, 9-52.
Clements, P., Benasutti, K., & Henry, G. (2001). Drawing from experience. Journal of Psychosocial Nursing, 39 (12), 12-20.
Gil, E. (1991). The healing power of play. New York: Guilford.
Lonetto, R. (1980). Children’s conceptions of death. New York: Springer.
Malchiodi, C. A. (1997). Breaking the silence: Art therapy with children from violent homes. New York: Brunner/Mazel.
National Association of School Psychologists. (2001). Helping children cope with loss, death, and grief: Response to a national tragedy. Available online at <www. nasponline. org>.
Webb, N.B. (2001). Helping bereaved children (2nd ed.). New York: Guilford.