Everyone experiences loss in their life. Loss is a normal, but destabilizing experience. Following a major loss, many secondary losses may occur. For example, a child that loses a parent may be required to move, changes schools, or other caregivers may withdraw due to their own grief. Complications may ensue if there are expectations that grief should be expressed in some specified way, or only in certain situations, or be time limited. The types of losses that can be experienced by children and adolescents are extensive: divorce, death of a sibling, parent, or peer, death of a pet, incarceration of a family member, loss of family members following removal by child protective services, loss of trust in a caregiver after being abused, and loss of a teacher at the end of the school year. Loss also occurs following graduation, when moving to a new neighborhood, and a friend quits a friendship. Other types of loss include deterioration of abilities or activities due to a medical or psychiatric illness, reduced contact with a parent following deployment or increased travel for work, a sibling going to college, loss of nurture, attention and support from a caregiver following a physical or psychiatric illness, a teacher leaving in the middle of a school year, and the end of a sports season. Some losses are related to maturation and development. For example, a five-year-old who is no longer “given a pass” when they grab a toy from a sibling has lost an indulgence given to someone who is less mature. Other maturational losses include a shift of parental attention to a new born, learning to self-sooth, becoming responsible for bathing, and cleaning up one’s own toys.
An individual’s reaction to a loss is not only defined by the nature of the loss. For example, a child may react to the loss of a parent through deployment in the same manner they react to the death of a caretaker. A child’s reaction to a loss is affected by their developmental stage and level of cognitive abstraction. For example, the experience of the loss of a meaningful relationship or an attachment figure by an infant or toddler results in regression and bodily symptoms. Children in this age group are likely to experience confusion and have trouble understanding the loss, especially if it is a profound loss such as the death of a caregiver. Young children, ages 2 to 5 years old, may perceive death as temporary. They are likely to demonstrate increased emotionality, more intense separation difficulties, engage in repetitive play and question asking, and magical thinking. Younger children may talk about wanting to die so they can be with a loved one, and older children may focus more on factual information. Children ages 6 to 9 years old understand the permanence of death. They may engage in behaviors similar to younger children. Grief is often expressed in “spurts.” Some children may assume that they are responsible for the loss. Other behavioral challenges, such as aggression or hyperactivity may emerge. The child may become whinier, experience insomnia, or have nightmares. Preteens may experience feelings of isolation, loneliness, fear, confusion and guilt. Adolescents may attempt to hide their emotions and engage in high risk behaviors such as abusing drugs and alcohol or staying out late. There may be a deterioration in academic performance, sleep and appetite disruption, or an increase in uncooperative behavior. Emotional reactions can include loneliness, confusion, guilt and worry.
While there are several games available that are directly related to grief and loss, the clinician may choose to focus less directly on grief and loss, and more directly on other concerns. For example, self-esteem, cooperation, or impulse control. Games are one type of intervention that will be used with children experiencing loss and grief. Other interventions may include story-telling, non-directive therapy, mindfulness, and supportive counseling. Only after a careful and thorough assessment can a determination be made about what interventions will be most useful and when to us a specific intervention. Ultimately, we work with our clients to become fully engaged with their school, friends, and family. In some situations we may direct much of our attention to the caregivers. It is important for us to understand how caregivers are handling the loss, and their availability to nurture and care for our client.
In this post I’ll focus on activities for younger children.
Cootie© Storytelling Game
When working with preschool child much of our intervention may be focused on the parent(s). When we see the child individually the bulk of our work may be nondirective. However, there may be times that we want to directly engage the child in a structured activity and address specific concerns. The Cootie© Storytelling Game, developed by the author, can be useful for communicating information and processing thoughts and feelings. This modified version of the Cootie game introduces a therapeutic element. In this version of the Cootie game the clinician constructs a story, with the client, to address specific concerns. The object of the game is for each of the players to construct their own Cootie and share in the story-telling. Traditionally, the first player to complete their Cootie wins the game. In the therapeutic version, it is not necessary to have a winner. The goal is to complete the story.
Game Play: In the Cootie game players collect body parts by rolling a die and then uses these parts to build a Cootie. Each Cootie consists of a body, head, eyes, antennae, proboscis, and six legs. Each part of the body is identified by a number as follows: 1-Body, 2-Head, 3- Antenna, 4-Eye 5-Probobcis, and 6-Legs. A picture guide illustrating which body part goes with each number is included with the game. There are two ways to begin Cootie. Each player rolls the die once and the high score starts the game, or the youngest (visitor) may go first. Each player tries to get the body of the Cootie by rolling a "one" spot. If he succeeds, he gets a free roll of the Die, to try for the head. The body and the head must be obtained in sequential order, before any other parts of the Cootie can be attached. The legs, eyes, antenna, and eyes can be acquired in any order; all are eligible after the body and head are obtained. The player loses the Die when he fails to roll the number for an eligible part that they have not yet acquired. For example, if the player rolls a 4 and already has the eyes, then the die gets passed to the next player. If they roll a 4 and don’t yet have the eyes, they pick them up and roll again. One body, one head, one pair of eyes, two antenna, one proboscis, and six legs are required to make a complete Cootie. Once the body and head are acquired all the other body parts can be acquired in any order. In the therapeutic version, parts are acquired but must be added to the Cootie in order, so that a story can be told that makes sense. If a part is acquired out of order, for example a leg before Cootie has a proboscis, the part is picked up and set aside until it can be added.
This story was created with a four-year-old child whose father was recently incarcerated. After several months, the child was still exhibiting considerable distress about not seeing his father. At first, the child had been told the father was away driving a truck, but after overhearing a conversation among the adults at home, the client learned his father was in jail.
When a one is rolled and the body is acquired each player says: “Cootie is thinking about his Dad today.”
When a two is rolled and the head is acquired each play says: “Cootie wants to see his Dad, but his Dad is in jail.”
Players are now eligible to acquire body parts in any order, but they are added to Cootie in the order listed below. When the eyes are acquired each player says: “Cootie wants to know when his Dad is coming home, so he can see him.” and the player attaches the eyes to Cootie. If the player has already acquired the antenna, then that can now be added.
When the antenna is acquired and added each player says: “Cootie’s Mom said Dad is coming home next year. Cootie is 4. Next year he will be 5. That’s when his Dad is coming home” as they attach the antenna to the head.
When the proboscis is acquired each player says: “Cootie likes to talk about his Dad and look at pictures of his Dad” as they add the proboscis to Cootie.
Each leg may represent a skill, affirmation, or important piece of information. Here are some examples:
After each Cootie is completed, the story is retold, repeating each statement as the appropriate body part is pointed to.
If the child is able to engage in a turn-taking game such as Candy Land©, it too can be modified to work with children experiencing a loss. Prior to playing the Candy Land game the therapist prepares a set of prompts. It is recommended that there be 10-15 prompts on the list. Prompts can cover any topic the therapist chooses. For example, cooperation and sharing, handling frustration, or coping with anxiety. In this version of Candy Land players move their pawn around the Candy Land board the standard way. When the player land on a square that is the same color as their pawn, they respond to a statement or question from the list of prompts.
Below are some sample prompts for dealing with loss, following the death of a classmate. Prompts are read aloud by the clinician, and language is modified as appropriate for the client. When the clinician responds to a prompt, the response should be constructed to address the clients needs.
Click here to read Part Two. The next post will focus on games and activities for children and adolescents.