1. Instructions on use of this template: Please remove this slide (slide 1) prior to use. This PowerPoint was created by child life specialists on the Child Life Council’s Professional Resources Committee as a resource for use by professionals in the field. It may be used to educate multidisciplinary team members and students in your practice. You may use it “as is,” or you may customize it by adding graphics or photos, selecting only a subset of slides, or integrating some of the slides into your own presentation, as appropriate for your audience. Please include the next slide (slide 2) in your presentation, either at the beginning, or end. Please refer to the speaker notes included with each slide, these are rich in detail!

2. Our Thanks to: The Child Life Council’s Professional Resources Committee, who provided the template to help in the creation of this presentation for our audience.

3. Bereavement Support for Children This presentation provides a basic overview of some of the most common reactions, concerns and misconceptions children experience when faced with bereavement, specific to each age group. Please remember: Every child, and every loss, is unique.

4. Key Points Children experience the world through play. Children will “self-dose” the amount of information they can handle. “Meet the family where they are!” Provide open and honest information. Use the words death, dead and dying. Reassure children that the death is not their fault.

5. Age Groups Infants (birth - 12 months) Toddlers (12 - 36 months) Preschoolers (3 - 5 years) School Age Children (6 - 12 years) Adolescents (13+ years)

6. Infants (birth-12 months) How they understand death: o Death is experienced as a separation. o Changes in routine threaten an infant’s sense of security. Key points in the hospital setting : o Infants mirror the emotional state of adults. o Stranger anxiety commonly occurs at 8 to 15 months of age. o Separation anxiety commonly occurs at 10 to 18 months of age.

7. Infant patients What to tell caregivers: o Maintain the infant’s routine. o Meet immediate physical needs. o Provide extra snuggles. Materials/Services: o Offer a legacy item. o Offer to sit with the infant while family takes a break. Warning signs of poor coping: o Watch for disruption of attachment bonds. o Watch for signs of depression in the adults.

8. Infant visitors What to tell caregivers: o Maintain the infant’s routine. o Meet immediate physical needs. o Provide extra snuggles. Materials/Services: o Offer a legacy item. Warning signs of poor coping: o Watch for disruption of attachment bonds. o Watch for signs of depression in the surviving caregiver(s). o Discuss concerns with the infant’s pediatrician, or caregiver’s primary care provider.

9. Toddlers (12-36 months) How they understand death: o Death is primarily experienced as a separation. o Toddlers have little concept of the permanency of death. Key points in the hospital setting : o Use concrete language, including the words “death, dead, dying.” o Offer appropriate play items.

10. Toddler patients What to tell the caregivers: o Maintain their routines as much as possible. o Provide plenty of play opportunities. Materials/services: o Offer a legacy item, books/resources. o Offer to sit with the toddler while the family takes a break. Warning signs of poor coping: o Poor coping may manifest as tantrums, sleep disruptions, or regression.

11. Toddler visitors What to tell the caregivers: o Maintain their routines as much as possible. o Provide plenty of play opportunities. o Use concrete language, repetition, and patience. Materials/services: o Provide safe play materials. o Offer a legacy item, books/resources. Warning signs of poor coping: o Poor coping may manifest as tantrums, sleep disruptions, or regression. o Discuss concerns with the toddler’s pediatrician.

12. Preschoolers (3-5 years old) How they understand death: o Preschoolers are sensory learners, with limited understanding of the permanency of death. o This is the age of magical thinking. o It is common for a preschooler to believe that they caused the death through their thoughts/wishes. Key points in the hospital setting : o Explain death as a sensory experience. o Watch for signs of misconceptions.

13. Preschooler patients What to tell the caregivers: o Provide reassurance and play opportunities. o Model healthy emotional expression. o Review that “bad thoughts” do not cause an illness. Materials/services: o Provide appropriate play materials. o Offer a legacy item, and books/resources. Warning signs of poor coping: o Watch for misconceptions about the cause of illness. o Pretend-play about injury/illness/death is normal.

14. Preschooler visitors What to tell the caregivers: o Provide reassurance and play opportunities. o Model healthy emotional expression. o Review that “bad thoughts” do not cause an illness. Materials/services: o Prepare a preschooler prior to a bed-side visit. o Offer a legacy item and books/resources. Warning signs of poor coping: o Watch for signs of misconceptions about cause of death. o Discuss concerns with the teacher or pediatrician.

15. School Age Children (6-12 years old) How they understand death: o Younger children are sensory learners, and may still think of death as reversible. Older children understand the finality of death. o It is normal to ask direct questions, and show interest in the physical aspects of death. Key points in the hospital setting : o Answer questions honestly and directly. o Provide lots of play opportunities. o Normalize the full range of emotions, and the desire to play.

16. School age patients What to tell the caregivers: o Encourage healthy emotional expression. o Normalize and encourage play. o Children may attempt to reflect adult grief patterns. Materials/services: o Offer a legacy item, and books/resources. o Offer activities to encourage emotional expression. Warning signs of poor coping: o Watch for changes in sleeping/eating patterns, disruptive behavior, or non-compliance with medical staff.

17. School age visitors What to tell the caregivers: o Encourage play and emotional expression. o It is normal for children to fear their own death. Materials/Services: o Offer a legacy item, and books/resources. o Prepare children prior to a bed-side visit. Warning signs of poor coping: o Watch for changes in sleeping/eating patterns, disruptive behavior at school, or excessive testing of boundaries at home. o Discuss concerns with the teacher or pediatrician.

18. Adolescents (13+ years) How they understand death: o Death is understood to be permanent and universal. o They may question their faith/religion & self-identity. o Behaviors may alternate between adult/child like. Key points in the hospital setting : o Provide adolescents with privacy and respect. o Expect inconsistent and contradictory responses. o They may look to their peers for support, including texting and social media.

19. Adolescent patients What to tell the caregivers: o Allow peer support, be patient with contradictory behavior, and address risk-taking behaviors promptly. o Model healthy emotional expression. Materials/services: o Offer a legacy item, and books/resources. o Offer therapeutic activities to encourage emotional expression. Warning signs of poor coping: o Watch for social withdrawal, changes in sleeping/eating patterns, and risk-taking behavior.

20. Adolescent visitors What to tell the caregivers: o Allow peer support, be patient with contradictory behavior, and address risk-taking behaviors promptly. o Model healthy emotional expression. Materials/services: o Offer a legacy item, and books/resources. Warning signs of poor coping: o Watch for social withdrawal, changes in sleeping/eating patterns, and risk-taking behavior. o Get support from teachers, peer-support groups, and pediatricians.

21. Legacy Items Ink prints (hand, foot, fingers, etc.) Lock of hair Thumb print medallion 3D hand replicas Photos, scrapbooking Video or audio recordings Artwork Letters for the future Memory box

22. Books No Matter What by Debi Gliori (infant/toddler/preschooler) Lifetimes by Bryan Mellonie & Robert Ingpen (toddler/preschooler/school age) When Dinosaurs Die by Laurie Krasny Brown & Marc Brown (preschooler/school age) The Saddest Time by Norma Simon (school age) The Next Place by Warren Hanson (adolescent) When A Friend Dies by Marilyn Gootman (adolescent)

23. Guided Journals & Other Resources Sesame Street: When Families Grieve Fire in my Heart, Ice in my Veins by Enid Traisman (adolescent) When Someone Very Special Dies by Marge Heegaard (school age/adolescent) When Someone Has a Very Serious Illness by Marge Heegaard (school age/adolescent)

24. Child Life Services (customize this slide with contact information, availability, and services.) Contact Child Life Services by (call, page, email, consult) Child Life Services offers the following end-of-life support services: o Consultations with caregivers (by phone or in person). o Support for pediatric patients, siblings, and children of adult patients. o Support prior to, and during, hospital visits. o Diagnosis teaching play. o Legacy items, and books/resources. o Psychosocial support.