Art Therapy With Children Experiencing Grief

This work seeks to answer the question of: “What is the effectiveness of art therapy with children that are experiencing grief?

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Art therapy is a form of therapy that was first utilized by the mental health profession in the decade of the 1930s. Presently, art therapy is practiced in various hospitals, public and community agencies, clinics, wellness centers, educational institutions, business and private practices alike and involves the “application of a variety of art modalities including drawing, painting and clay sculpture.”(Natural Standard, 2008) This work will explore Art therapy for used with children who are experiencing grief and will examine the effectiveness of this type of therapy for children dealing with grief.

According to the work of Busch and Kimble (2001) “One out of every 20 American children under the age 15 loses one or both parents due to death. It is estimated that in a secondary school of 800 pupils, 24 children will experience the death of a family member. Death of a sibling profoundly affects children, and its repercussion can be with the child throughout life.” Children experience great difficulty in expressing their needs and feelings related to grief making it critically necessary that nurses, health care professionals and educators who work with grieving children understand how they can best support the child in coping with the grief in order that the child move on with their life rather than becoming disabled by their experience of grief.


The work of Malchiodi (2003) entitled: ‘Using Creative Activities as Intervention for Grieving Children’ published by the National Institute for Trauma and Loss in Children states that the National Association of School Psychologists (2001) states that the range of children’s grief reactions are as follows:

1) 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;

2) 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;

3) 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;

4) 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. (Malchiodi, 2003)

It is oftentimes assumed by adults 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 or beliefs about death.” (Malchiodi, 2003) However, children, depending on their ages and stages of development “understand death and loss in different ways.” (Malchiodi, 2003) Malchiodi states that the work of Webb (2002) differentiates the grief of children from that experienced by adults as follows:

Children’s immature cognitive development interferes with their understanding about the irreversibility, universality, and inevitability of death;

Children have a limited capacity to tolerate emotional pain;

Children have limited ability to verbalize their feelings;

Children are sensitive about ‘being different’ from their peers; and Children are able to express their feelings in play therapy. (Malchiodi, 2003)

Children’s understanding of death may be varied depending on the age and stage of the child’s development in that young children “fall into Piaget’s preoperational stage” which is a time when children “begin to represent their world with words, images, drawing and imaginative play activities.” (Malchiodi, 2003) During this stage of development, because children this age are egocentric, the child may believe that they somehow caused the death of the individual. Furthermore, magical thinking that occurs at this age may cause the child to believe that the individual might be brought back somehow as they do not realize that death is irreversible. Children in the age range from seven to eleven years of age “…fall into Piaget’s stage of concrete operations” which is a stage characterized by “reduced egocentricity and an improved capacity for reasoning.” (Malchiodi, 2003) During this stage of development “children develop organizational skills, learn to read, and to use language more proficiently, signaling their developing cognitive abilities.” (Malchiodi, 2003) During this stage children find difficulty in the irreversibility of death. Older children in the age range from eleven to fifteen years of age “are in Piaget’s formal operational stage and enter a more mature time of thought and understanding.” (Malchiodi, 2003) During this stage of development, “thinking becomes more logical” and children develop the capacity to “handle several variables at once, and they are capable of handling abstract ideas.” (Malchiodi, 2003)

Malchiodi (2003) states that “drawings have proven to be a good reflection of children’s abilities to conceptualize death in abstract terms.” Malchiodi states that the process of grief is difficult in “normal circumstances” however it is “often more intense if a sudden, traumatic death is experienced.” (Malchiodi, 2003) This is because death that is due to homicide or domestic violence is often “complicated by a legal inquiry, interactions with law enforcement, and sensational or even inaccurate coverage by law enforcement.” (Malchiodi, 2003) Ongoing contact with the different agencies and investigators tends to “deepen the sorrow, confusion and suffering of survivors, particularly children who may be trying to make sense of what has happened.

Malchiodi states that drawing has been found in research studies to be “…particularly effective with those children who can make recognizable drawing of people, animals, houses, tree and other aspects of their environment.” (2003) Furthermore, it is believed that drawing “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.” (Malchiodi, 2003) the drawings of children literally illustrates.”..their fears, adaptive coping skills, and beliefs about death and dying. They offer an avenue of information” which can assist in the formulation of interventions for the future and for recognition of grief responses that are more serious in nature. Malchiodi (2003) states that activities that are set out in the work of Steele, Malchiodi and Klein (2003) entitled ‘Helping Children Feel Safe’ include the following:

What’s Your Worry? – Children are asked by therapists and counselors to draw their feelings, especially their worries and fears.

Transform Your Worry – a drawing of something such as a sorry may be utilized in assisting the child to transform what is worrying them into something less troubling or frightening.

Magic Book – This is a method used for empowering children in seeking their own solutions to that which worries them and helps children cope with their fears;

My Safe Box – This involves the creation of a memory box and is a process by which a box is used to contain the child’s memories including objects fashioned from clay in representation of people or events, drawings of the deceased, family photos and other small mementos that are representative of the positive experiences the child had with the deceased. (Malchiodi, 2003)

Malchiodi (2003) states guidelines for assisting children with grief include the follows:

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); and 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. (2003)

The work of Fiorini and Mullen entitled: ‘Understanding Grief and Loss in Children’ states that “grief and loss experiences of children and adolescents are demonstrated emotionally. Regardless of the type of loss, the child may experience feelings of emptiness, anger, confusion, desertion, and insecurity. In addition, he or she is almost certain to feel responsible, and guilty about the loss he or she has experienced.” (nd) Behavioral manifestations of the inability to cope with feelings of grief include “angry outbursts, irritability, sleeping and eating disorders, and persistent questioning about the details of death.” (Fiorini and Mullen, 2007) Frequent expression of grief in childhood and adolescence include “fear of personal fallibility, psychosomatic ailments, and difficulties with schoolwork, nightmares or sleep disorders, changes in eating patterns, temporary regressions and shock.” (Fiorini and Mullen, 2007) Fiorini and Mullen note that four tasks were outlines by Fox (1985) in assisting children with understanding their grief, commemorating the loss and with moving on with their life. It is stated that interventions that have been successful in children who are dealing with grief include those of “play therapy, narrative therapy and art therapy.” (Fiorini and Mullen, 2007)

The work of Nabors (2004) et al. entitled: ‘A Pilot Study of the Impact of a Grief Camp for Children’ relates a study in which states findings that “children reported that art activities helped them to express feelings about their grief and release feelings of sadness and worry related to the death. Parents and children felt that the camp was a positive experience and that the children benefited from being in groups with peers who had also lost family members.” (2004)

The work of Busch and Kimble (2001) entitled: ‘Grieving Children: Are We Meeting the Challenge’ published in the Journal of Pediatric Nursing states that “an effective way to help children develop strategies to cope with loss is though a bereavement support groups. The use of art therapy, recreation, psychodrama, puppets, workbooks, discussions, writings and other supportive activities are all structured into sessions that help children express grief openly and receive support from others who are grieving.” (2001) the primary purpose of the group is “not to achieve resolution of grief, but rather to give the students the skills and support to continue to work toward resolution of their grief.” (Busch and Kimble, 2001)

The work of Graham and Sontag (2001) entitled: ‘Art as an Evaluative Tool: A Pilot Study’ published in Art Therapy: Journal of the American Art Therapy Association relates a study that examined the effectiveness of an art therapy support group for children who were grieving. The assessment utilized artwork for making qualitative measure of the perspective of the experiences in this group of children. Results of the study state that evaluation of perceptions of the children’s grief “was conducted retrospectively at a ‘reunion’ of the group one year after completion of a 10-session treatment program.” (Graham and Sontag, 2001) it is stated that three themes emerged in this study as follows:

1) the vulnerability of grieving children;

2) the importance of maintaining memories; and 3) the contribution of the group to the process of grieving. (Graham and Sontag, 2001)

Findings are stated to indicate “that art can be an effective tool to evaluate children’s grief groups.” (Graham and Sontag, 2001) the work of Ellenbecker and King (1990) entitled: ‘The Effects of Gender and College Major on Mood State Changes Induced through Artistic Expression’ published in the American Journal of Art Therapy states that “a basic tenet of art therapy is that the process of creating art is associated with positive mood change.”

The work of Nicole Resnick (2005) entitled: ‘It’s All Right to Cry: How to Help Kids Cope with Death, Dying and Grief’ relates a story in which a child is asked why he believed his grandfather had died and the little boy confided that “he felt he was responsible” as he had “accidentally stepped on his grandpa’s oxygen tube the same night the terminal man passed away.” (Resnick, 2005) Resnick expressed that had this child not had the chance to voice this belief “he may have harbored this misguided guilt for years.” (2005) the tendency, according to Resnick is to not speak about grief however, this is a tendency that is very ineffective in assisting the child who is coping with grief over the death of someone close to them. Resnick specifically states: “For many young children, art therapy is a highly effective approach to managing the grieving process.” (Resnick, 2005) Resnick relates that a bereavement counselor and art therapist at HospiceCare, Molly Tomony “…says the philosophy of this growing field is that we all have an inherent capacity to create, when it is difficult to articulate feelings verbally, there are other ways to express feelings and struggles.” (2005) in fact, many things are revealed through children’s artwork. Resnick share the story of Tomony who states “…she once taught a little boy who drew a picture of the battle being waged between the good healthy cells — drawn in red — and the bad cancerous cells — drawn in black — inside his father’s body. Very perceptive, Tomony thought, but she also noticed many black cells drawn along the bottom of the paper, outside of his father’s body. When asked what they meant, the child said that they represented the cancer cells that came off of his dad’s feet as he walked. That is why, the child explained, he always wore shoes at home — to avoid catching cancer from the cells on the floor.” (Resnick, 2005)


Findings in this study indicate that art therapy is a very effective method is assisting grieving children in coping with the loss of a loved one. Children often harbor erroneous beliefs and misconceptions about the reason the loved one has died and furthermore, often harbor misplaced self-guilt concerning the death of their loved one. Art therapy is highly effective in assisting children in the expression of their grief and furthermore, is highly effective in assisting children in moving on with their life avoiding depression and self-guilt associated with the death of their loved one.


Recommendations that have arise during the course of this study for future research include a recommendation that more research be applied to understanding how children process the death of a loved one and the various forms of guilt that children attach to self related to the death of a loved one. Furthermore, future research should focus on understanding precisely how children represent grief and death and how this conceptualization of death is portrayed in their artwork and specifically as related to death by disease and how this relates to the child’s feelings of safety and security following the death of a loved one by diseases such as cancer.


Art Therapy (2008) National Standard – the Authority on Integrated Medicine. Online available at

Malachiodi, Cathy a. (2003) Using Creative Activities as Intervention for Grieving Children. Trauma and Loss: Research and Interventions Vol. 3 No. 1, 2003. The National Institute of Trauma and Loss in Children. Online available at

Fiorini, Jody J. And Mullen, Jodi a. (2007) Understanding Grief and Loss in Children – Article Seven.

Nabors, Laura, et al. (2004) a Pilot Study of the Impact of a Grief Camp for Children. Cambridge Journals Palliative and Support Care 2004 Vol. 2-19 Jul 2005. Online available at;jsessionid=8DE0B69D35D46519FE4401EA5F569E1C.tomcat1?fromPage=online&aid=315560

Busch, Teri; and Kimble, Cathy S. (2001) Grieving Children: Are We Meeting the Challenge? Pediatric Nursing July 2001. Online available at;col1

Resnick, Nicole (2005) it’s All Right to Cry: How to Help Kids Cope with Death, Dying and Grief. Madison Magazine. September 2005. Online available at

Art Therapy with Children Experiencing Grief