Addressing Children's Grief Head On From An Occupational Therapy Perspective

Editor's note: This text-based course is a transcript of the webinar, Addressing Children's Grief Head On From An Occupational Therapy Perspective, presented by Elizabeth Reymann, OTR/L.

Please also use the handout with this text course to supplement the material.

Learning Outcomes

After this course, participants will be able to:

• Recognize the role of occupational therapy in addressing and providing intervention to children who have experienced grief/loss of a parent, family member, pet, or sibling.
• Describe knowledge and an understanding of the incidences of grief with children in the U.S. and the lack of available resources for intervention.
• Identify helpful resources, suggested treatment techniques, and specific interventions from an occupational therapy perspective, with the goal of carrying these over into children's daily living skills.

Introduction

I am so excited to share this passion project of mine with you today. Children's grief is a topic that sits very close to my heart — both professionally and personally — and I believe occupational therapy has a unique and vital role to play in supporting grieving children that our field has only just begun to fully embrace.

A little bit about me: I have been an occupational therapy practitioner (OTP) since 1983, working in pediatric outpatient clinics, schools, and hospital settings, as well as in adult rehabilitation and home health. I am an Ohio State University graduate with a minor in Music Therapy. Over the decades, I have earned certifications in Early Intervention, Yoga for the Special Child, the Windbridge Institute, the Forever Family Foundation, and Learning Without Tears, and I am an AOTA Clinical Educator. I am also the author of Daysee the Delinquent Angel, Last Wishes, and There's a Man Standing Next to You. I have developed and delivered seminars on my Intuitive Tools 4 Kids program, which covers working with children who are grieving, meditation, and the therapeutic benefits of journaling.

Much of the material I'll share today has grown from decades of clinical work and from my volunteer involvement with grief-focused organizations, including the Forever Family Foundation and the Windbridge Institute. I want you to leave today with practical tools you can use immediately — tools grounded in our scope of practice that will help children who are hurting find their way back to their daily lives.

Childhood Grief: Why It Matters

Before we dive into intervention, I think it is essential that we understand the scope of this issue, because the statistics are sobering. According to the National Alliance for Children's Grief, 1 in 12, or 8.3%, of children in the United States will have experienced the grief of a parent or sibling by the time they are 18 years old (National Alliance for Children's Grief [NACG], 2023). In 2023, 6.3 million children had experienced the loss of a parent or sibling, and during COVID alone, 72,000 children in the U.S. lost a parent (NACG, 2023). Those are not abstract numbers — those are children on our caseloads.

Childhood grief, when it is not supported effectively, carries a strong potential for future developmental disruptions, substance abuse, suicide, and poverty (NACG, 2023). I have witnessed this in both my personal and professional life. The absence of skilled support is not a neutral outcome. When we fail to intervene, we are potentially contributing to a trajectory of harm.

What Is Grief to a Child?

Grief is the response to the loss of something deemed important, particularly the loss of someone or some living thing who has died to which a bond or affection was formed (Wikipedia, n.d.). That definition covers parents, siblings, grandparents, and yes — pets, whose loss is often minimized but can be devastating to a child.

Children's typical responses to grief often look quite different from how adults grieve, and they can show up in ways that look like behavioral or developmental concerns rather than an emotional response to loss. We commonly see withdrawal from socialization, clinging to adults, frequent crying, regression in self-care, sensory regulation problems, decreased concentration, anger outbursts, and avoidance behaviors such as rebellion from previous routines — like refusing to go to school, difficulty getting up in the morning, or resistance to a regular bedtime (Milliken et al., 2007).

I want to share a brief clinical example that has stayed with me for years. There was a little boy I treated who was about eight years old. He had been a neat, together kid, and then one day, he started to decline in his dressing skills. He wore the same sweatshirt almost every time I saw him; he just didn't look good, and he wouldn't tie his shoes. About a week into this, we found out that his father had passed — suddenly, and in a violent situation. He and the teachers did not know what was happening. He was out for a couple of days, and then we saw those shoes. That story is the reason I now always consider grief as a differential when I see regression in a child's ADL performance.

Teachers of school-age children who have experienced loss consistently report increased absenteeism and decreased academic performance (Milliken et al., 2007). As occupational therapy practitioners, we are positioned to recognize these patterns, identify the underlying causes, and respond meaningfully.

Children's Grief and the DSM-5-TR

For those interested in potentially billing for this area of practice, it is worth noting that Prolonged Grief Disorder (F43.8) is recognized in the DSM-5-TR (American Psychiatric Association, 2022). The diagnostic criteria include the death of a person who was close to the bereaved, at least 12 months ago for adults, but notably only six months ago for children and adolescents. Importantly, the symptoms must not be better explained by another mental or emotional disorder, such as major depressive disorder or PTSD.

The clinical presentation of prolonged grief disorder in children includes intense longing for the deceased person, intense emotional pain such as anger or bitterness, preoccupation with memories of the deceased — which may focus on the circumstances of the death if it was witnessed — and difficulty re-engaging with relationships and previous activities. The final two criteria are particularly relevant to our work: clinically significant emotional distress that affects occupational and important areas of functioning, including ADLs and IADLs (American Psychiatric Association, 2022). Those functional domains are precisely where occupational therapy should direct its focus.

Awareness of Cultural and Religious Diversity in Grief

As occupational therapy practitioners, we bring a client-centered, culturally responsive lens to everything we do, and grief is no exception. The children we treat come from enormously diverse religious and cultural backgrounds, each of which shapes how death is understood and how grief is expressed and supported.

In Christian traditions, there is a belief that the deceased go to a place of eternal afterlife; within Catholicism, last rites carry deep significance and the hope of forgiveness. Jewish tradition holds that death is not a tragedy; funerals are typically held as soon as possible after death, followed by Shiva, a seven-day mourning period after burial (Health Care Chaplaincy, 2009). Buddhist beliefs center on cycles of death and rebirth, with a peaceful death as the goal and family preparation of the body prior to cremation as an important ritual. Hindu belief encompasses karma and reincarnation, with the ashes of the deceased scattered in sacred rivers. In Muslim tradition, there is a belief that the soul travels to the afterlife and requires a quick burial so the soul may be freed; flowers and excessive mourning are actually discouraged (Health Care Chaplaincy, 2009). I did not know that last part before I did my research — and it matters. I would not now send flowers to a Muslim family who had experienced a loss.

This overview is not exhaustive, but it underscores that our approach to grief intervention must be flexible, culturally humble, and always individualized to the family in front of us. Ask, listen, and never assume.

What the OT Literature Tells Us

I spent the better part of two years reviewing the occupational therapy literature on childhood grief, and I want to highlight three studies that shaped my thinking and that I believe still carry significant clinical relevance today. I will say with a smile that one of them is from 2007 — which I know might feel like a long time ago — but I feel it still pertains entirely to the situation we are in right now.

The first, published in 2007 by Milliken, Goodman, Bazyk, and Flinn, was titled "Establishing a case for occupational therapy in meeting the needs of children with grief issues in school-based settings," published in Occupational Therapy in Mental Health (Milliken et al., 2007). These researchers created a survey for OT practitioners working in Ohio school districts, designed to capture the current level of awareness of grief issues among children on their caseloads, and to understand what tools and comfort practitioners had in addressing it. Their conclusion is the one I keep returning to: occupational therapy, with its emphasis on participation and meaningful occupations, is uniquely capable of being a catalyst in the healing process for children dealing with grief (Milliken et al., 2007). I think it is worth sitting with that for a moment. Not just capable — uniquely capable. Because of our emphasis on participation and meaningful occupation. That is our professional identity, describing exactly this work.

The second is a 2022 study from South Africa by Ramamo, Pretorius, de Jager, Oldfield, and Moriti, examining occupational therapists' perceived ability to treat and assist bereaved individuals in finding new meaning through engagement in therapeutic activities. This one is more general — it addresses bereavement across populations rather than specifically children — but its findings are important. The study revealed that there is limited knowledge and literature available to occupational therapists treating bereaved individuals, and that significant barriers exist due to a lack of training and education in this area (Ramamo et al., 2022). The existing literature is skewed toward adults, leaving practitioners who work with children largely without a framework. That is a gap this course is directly designed to help address.

The third is a 2022 study in the Brazilian Journal of Occupational Therapy by Saciloti and Bombarba, which examines exploratory aspects of how occupational therapists approach grief intervention. Their conclusion was similar in tone: limited paradigms, scarce literature, and an awareness among OTs that this is a domain they should address, but without adequate standardized tools to do so (Saciloti & Bombarba, 2022). OTs in their study expressed a belief that they have something to offer bereaved clients, but felt under-equipped to formalize it.

What strikes me across all three studies is the consistent message: there is a clear and documented need, there is a well-matched professional role, and the field has simply not yet built the infrastructure to support it systematically. That recognition is not discouraging to me — it is motivating. It means there is genuine work to be done, and that what we bring into practice today matters.

Why OT Intervention for Grieving Children?

Occupational therapy's role in addressing children's grief is not a stretch of our scope — it is a natural expression of it. Our practice sits squarely within the occupational domains that grief disrupts: ADLs, IADLs, play, rest, sleep, education, and social participation. Using purposeful activities to promote mental health and well-being is central to what we do. And our holistic orientation — treating the whole person across their environments — is exactly what grieving children need.

We are also skilled in both group and one-on-one therapy formats, which gives us enormous flexibility. Some children do their best processing in a peer group, surrounded by others who understand their experience. Others need the privacy and trust of an individual therapeutic relationship. As OTPs, we can provide both.

What I have come to believe deeply, after decades in this field, is that occupational therapy can provide a vital service with creative and comforting interventions for children coping with grief and loss by engaging them in their purposeful occupations of play and daily living skills. Play is how children make sense of the world. Daily living skills are how they navigate it. When grief disrupts both, OT is positioned to restore both.

OT Interventions for Grieving Children

Empathic Listening

The foundation of everything I do with grieving children is empathic listening. I know many of us, when we encounter someone who has experienced a loss, instinctively say, "I'm sorry for your loss" or "I know how you feel." Those phrases, while well-intentioned, can inadvertently close a conversation. Empathic listening is different—it is active, open, and communicates that the child is fully heard.

In practice, I use phrases like "I hear what you're saying," "Tell me more about this feeling," or simply "I'm listening." These invitations build trust and open a child to expressing themselves — verbally, through art, or through play. Do not underestimate this step. Without a therapeutic foundation of trust, none of the activities I am about to describe will land the way they need to.

Connecting With Nature

Connecting with nature is a powerful intervention that taps into the sensory and regulatory benefits of the natural world. In my practice and personal experience, I have found this to be one of the most accessible and emotionally meaningful modalities for children.

Gardening and planting a tree in memory of a loved one, rock painting, earthing — simply getting one's feet in contact with the ground or sand — quiet walking in a park or at the beach, water and sand play, and even pet therapy all fall within this domain. The sensory components are significant: the tactile input of soil and sand, the proprioceptive grounding of walking barefoot, the rhythmic quality of water.

I often use a personal example when I describe this intervention. When my mother passed away, my children were six and eight years old. We went to the beach together; they loved it, and we brought balloons. I told them to say something to Grandma, and they let the balloons go up. Then we placed flower petals in the water. That was about 20 years ago, and my now-adult children still talk about it. Connecting with nature gave us a ritual, a physical expression of something that had no other form. These are the experiences that stay with children.

Mindfulness

Mindfulness is something many children are learning in school settings today, and it translates beautifully to grief work. What I notice consistently is that when I introduce breath work or mindfulness activities, children naturally fall into a relaxed, receptive posture without much prompting. I always find that remarkable. This approach is developmentally effective across a wide range, from about age three through high school.

Practical mindfulness interventions include mindful coloring, meditation apps, music expression, mindful movement and yoga, interoception education, and breath work. A guided meditation is one of my favorite in-session tools, and I use it with a beach visualization that I find particularly effective. I guide children to close their eyes, take a slow breath, and imagine someone they miss walking toward them on the beach. They hold hands, they embrace, they share something silently, and then they say goodbye — peacefully, with the understanding that they are okay. Children have remarkable imaginations, and this type of guided visualization honors their inner world while providing a container for grief.

I typically meditate for a longer period when working with children, closer to 15 to 20 minutes, with calming music or ambient sounds in the background. For younger or higher-support children, I often place meditation at the end of the session so they can return to the classroom or home in a regulated state. For older children, I sometimes begin with it to create focus and emotional readiness for the activities that follow.

Journaling and Self-Expression

Journaling is a wonderfully adaptable intervention that meets children where they are developmentally. For young children or those with limited writing skills, emoji stickers, drawings, or single words work beautifully — you do not need a child to be literate for journaling to be meaningful. For middle and high schoolers who want to process more deeply, writing in full sentences or longer, more expressive pieces serves as a genuine outlet. I have even seen adolescents who begin as reluctant writers become quite prolific in their journals once they discover that no one is grading them and it is only for them.

Some specific journaling activities I return to often include writing a letter of love to the person who passed. This is one of my favorites because it gives the child permission to continue the relationship in a new form — to say the things they didn't get to say, to share what has happened since the loss, to tell the person they miss them. Daily journaling of thoughts and feelings is valuable for helping children build self-awareness and emotional vocabulary over time, particularly when paired with interoception activities. Sharing journals in a small-group setting allows children to support one another and recognize that their feelings are not unique or shameful—they are universal.

Creating a memory booklet is a variation I particularly love. The child assembles a small book of pictures, printed images, handwritten memories, and found objects — a pressed flower, a ticket stub, a photograph — anything that speaks to their relationship with the person they've lost. They can return to this booklet privately, keep it in their comfort box, or share it with family members. Collages made from magazine pictures offer a similar experience with a tactile component and require no writing, making them highly accessible. A finished collage can be framed and hung on the wall, becoming a permanent, visual honoring of the relationship.

Activities of Daily Living

Grief frequently disrupts children's daily living skills, and addressing those disruptions is core OT work. I want to return to the story of the eight-year-old boy I mentioned earlier — the one who stopped tying his shoes, wore the same sweatshirt almost every time I saw him, and wasn't looking like himself. He had been a neat, together kid before, and then something shifted. About a week after we noticed the regression, we learned that his father had crossed over — suddenly, violently. Nobody had told the school. The teachers didn't know what was happening. They just knew he had been out for a couple of days, and then he came back. And we saw those shoes.

That story is with me every time I encounter a child with unexplained ADL regression. Before we assume it's developmental, before we assume it's behavioral, we need to ask: what has this child lost recently? Because grief does not announce itself as we expect. It announces itself through untied shoes, through a sweatshirt worn too many days in a row, through a child who no longer has the internal resources to take care of himself the way he did before.

ADL interventions for grieving children include establishing a visual daily schedule with a timer to support self-care routines. Structure and predictability are enormously stabilizing for children whose world has just become unpredictable and unsafe. Creating a consistent daily routine — one that is communicated both at home and at school — gives children a container for their days when grief has taken away all the expected containers. Role-playing with dolls or stuffed animals is a non-threatening way to re-engage children with the steps of bathing, grooming, and dressing when those tasks have become overwhelming or avoidant.

Sleep disruption is nearly universal in children coping with loss, and it compounds everything else — sensory regulation, attention, mood, and academic performance. Sleep strategies, including calming apps, sound machines, weighted blankets, and a structured pre-sleep routine, are worth exploring with caregivers. I also encourage creating a calm corner in the child's bedroom — soft blankets, sound-reducing headphones if useful, and familiar comforting items — as a designated space for winding down.

I also love the idea of involving caregivers in meaningful co-occupation as a grief ritual. For example, baking a cake or cookies on a special occasion in memory of a loved one. Perhaps on Grandma's birthday, or on the anniversary of her passing, the family makes her chocolate chip cookie recipe together. That activity touches IADLs, involves the caregiver, connects to the sensory memory of the person who passed, and creates a new ritual of remembrance all at once. Those moments of co-occupation are where therapeutic goals and real life come together in the most meaningful way. And it is not lost on me that making cookies is also about taking care of yourself — nourishing yourself — which is an act of self-compassion for a grieving child.

The Five Senses Heart Activity

One activity I have developed and used across settings — with children and adults alike — is what I call the Five Senses Heart Activity. You need construction paper, scissors, and Band-Aids. That's it.

Have the child draw a heart approximately eight to ten inches in diameter. Inside the heart, they create five sections corresponding to each sense: seeing, hearing, scent, touch, and taste. In the center, they write the name of the person or pet they are missing. Then, in each section, they write or draw a sensory memory of that person — what it looked like to see them smile, what it sounded like to hear their name, what their perfume or cologne smelled like, what their hugs felt like, what their cooking tasted like.

After completing the heart, the child cuts it out and tears it into five roughly equal pieces. The act of tearing the heart can be very emotional — and that's intentional. Then they reassemble it using Band-Aids.

It sounds simple. But until you try it with a child, you may not fully appreciate how powerful it is. The tearing and the reassembling carry real meaning — grief breaks something, and we work to put it back together, marked by the experience but still whole. Children can take this home, keep it in their memory box, or share it with family. I have used this with children as young as four and with adults in their seventies. It lands every time.

Sensory and Movement-Based Activities

Because grief often manifests as dysregulation in children, sensory and movement-based interventions are a natural fit for our toolkit. I frequently use the Zones of Regulation as a framework to help children understand and name their emotional and sensory states. Heavy work movement integrated into the daily routine provides organizing proprioceptive input and helps children move out of a dysregulated state.

Stuffed toy hugging and weighted blankets address the need for tactile and proprioceptive input in a highly accessible, comforting way — and a child's cherished stuffed animal, especially if it belonged to or was given by the person who died, carries additional emotional weight that we can honor in therapy. Swimming and bike riding provide excellent proprioceptive and vestibular input. Aromatherapy using calming scents like lavender, vanilla, or orange can support focus and relaxation — and I always let the child choose their own scent, because individualization matters. Not every child loves lavender, and that's fine.

Creating a calm corner with blankets, sound-reducing headphones, and pillows is something I recommend for both home and classroom settings. Trampolining and swinging for vestibular input round out this category nicely.

Drawing and Painting Activities

Art-based interventions are among the most clinically versatile tools available to us. Finger painting is particularly powerful — and I want to name that it can be very emotionally activating in a way that brush painting often is not, because of the direct tactile involvement. Be prepared for strong emotions when you use it, and treat that as therapeutic information rather than a problem.

Other drawing and painting activities include painting pictures of loved ones, self-portraits of past, present, and future selves, collage creation, mural drawing on a large sheet of wall paper where each family member can contribute their own memory or image, drawing a house or a tree — both of which can offer rich projective information about a child's internal world — and painting a flower pot to grow something in memory of the person they've lost.

One of the most vivid examples of finger painting I have encountered in my career involved a child whose family member had drowned. The child used both hands, working first in dark black, then blue, re-painting what they imagined had happened to their loved one. Then they painted a boat with their hands. The activity allowed them to externalize and process something that had no words. If you want to really get the emotions out, use the whole hand — give the child that kind of full engagement.

The Comfort Box

Another resource I want to share is the concept of the child's personal **Comfort Box** — a small, portable collection of sensory and expressive tools that the child helps assemble. Involving children in creating their own comfort box is part of the intervention; it gives them agency and ownership over their own support.

What goes inside can include a palette of paints or crayons, a small journal for coloring or writing, a meditation coloring book for older children, a card with yoga poses, a heart rock to paint, a small photo frame for an image of the person they've lost, a small stuffed animal, calming essential oils in a scent the child has chosen, and flower seeds with a small pot to paint and plant. Not every item needs to make it into the box — the box should be individualized. The goal is a portable container of comfort that the child can reach for when needed.

Animal-Assisted Therapy

Animal-assisted therapy is a beautifully natural fit for children coping with loss. Dogs and cats, in particular, offer children a form of non-judgmental comfort that can be difficult to replicate through human interaction. Children will often tell an animal something they would never say aloud to a person, because the animal simply listens and comforts. Petting, grooming, and reading to dogs or cats provide simultaneous tactile, proprioceptive, and emotional connections.

Equine-assisted therapy offers additional sensory benefits — the vestibular input of riding, the proprioceptive engagement with the animal, and the surprising emotional opening that many children experience when working with horses. I have seen children verbalize feelings in an equine setting that they had held completely inside in a clinic room.

If you are considering starting or referring to an animal-assisted therapy program, organizations like Pet Partners are a well-established resource — I used Pet Partners when I worked at Phoenix Children's Hospital. Animals in a therapeutic setting require formal handler and animal training; they cannot simply be brought in. But the investment is well worth it.

Books and Videos as Therapeutic Tools

Reading and watching together are among the most accessible grief interventions available, and they are highly adaptable across developmental levels. Books can open conversations, provide language for feelings, and normalize the experience of grief in ways that a direct therapeutic conversation sometimes cannot.

Several books I recommend frequently include The Invisible String by Patrice Karst — available in a version for loss of a person and also for loss of a pet — Tell Me About Heaven by Randy Alcorn and Ron DiCianni, I Miss You: A First Look at Death by Pat Thomas, Lifetimes: The Beautiful Way to Explain Death to Children by Brian Mellonie, and The Goodbye Book by Todd Parr, which is particularly gentle for younger children.

Videos can be equally powerful, and I have used clips from the Inside Out films extensively in my practice. There is a scene in the original film in which Sadness sits with Bing Bong after he disappears and simply listens — she does not try to fix it, she just stays present. That is empathic listening in a form children immediately recognize and respond to. I typically show a five-minute clip, then do a brief discussion and follow up with a related art or journaling activity. The combination of media and hands-on processing is very effective.

Occupational Therapy Assessments for Pediatric Grief

Appropriate assessment is the foundation of evidence-informed intervention, and there are several tools worth incorporating into your evaluation process when you suspect or have confirmed grief as a clinical concern.

The Sensory Processing Measure-2 and Sensory Profile 2 are both excellent for capturing the sensory dysregulation that frequently accompanies grief responses in children. The Dynamic Occupational Therapy Cognitive Assessment for Children (DOTCA-Ch) can help identify the cognitive and attention-related impacts that grief often causes — decreased concentration, difficulty with task engagement, and regression in academic performance are all appropriate targets. The Pediatric Functional Independence Measure II (WeeFIM II) measures functional independence in self-care, mobility, and cognition, and can document regression resulting from grief-related disruption.

Clinical observations across settings are invaluable, as is a Draw a Person or House task, which can reveal much about a child's internal state and self-concept. The caregiver interview is critical—and I want to expand that definition to include teachers, because their observations of a child's school-based functioning can provide information a parent at home may not have access to.

Finally, I want to share the Pediatric Grief Questionnaire I developed, which I use to begin the conversation with children in a structured but accessible way:

1. Who in your life has passed away that you miss?
2. Did you go to their funeral? (Yes/No)
3. Did you get a chance to say "Goodbye"? (Yes/No)
4. What things or items do you have of theirs, if any?
5. Have you had any dreams of them since they passed? (Yes/No)
6. What do you miss the most about them?
7. Is there anything else you want to say?

For children who cannot write, you can read the questions aloud and record their responses. Some children answer briefly and move on; others keep talking. Either way, the questionnaire opens a door. Let them lead once it's open.

The Interdisciplinary Team and Caregiver Involvement

No matter how skilled our individual interventions are, the most effective outcomes for grieving children occur when the whole team is aligned. Occupational therapy does not operate in isolation, and grief certainly doesn't resolve within the walls of our clinic alone.

We must actively communicate and collaborate with school counselors, teachers, psychologists, social workers, and — most crucially — parents and caregivers. Parents and caregivers are the ones who can implement the structure, routines, and comforting activities we recommend across the hours and environments we do not have access to. Carryover is not a bonus; it is the mechanism through which change happens.

It is also worth remembering that some families are open to talking about the loss, while others would rather not. I find that more families are open to suggestions than we might initially assume, but we need to create space for each family to approach this at their own pace and in their own way. Our role is to provide skilled, compassionate support and practical tools — and then to trust the family and child to use them.

The director of the Inside Out films, Pete Docter, accepted his Academy Award in 2016 with a message that I think captures the spirit of this work perfectly. He said that for anyone in junior high, high school, or just working through something difficult — suffering, feeling sad, angry, scared — there are going to be hard days, but you can make something. You can draw, write, and create. It will make a difference. That is occupational therapy's message too.

Related Organizations and Community Resources

As occupational therapists working with grieving children, it is valuable to know what community resources are available to refer to and collaborate with.

Hospice of the Valley's New Song Center for Grieving Children in the Phoenix area is an excellent example of a community-based program that offers age-stratified grief support groups for children and young adults from kindergarten through age 21. If you are outside Arizona, many hospice organizations across the country have similar programs.

Amanda Hope Rainbow Angels supports families impacted by the loss of a loved one to cancer or other life-threatening illness, and hosts an annual Night of Hope event.

Experience Camps offers transformative summer camp experiences for children who have experienced significant loss, with programs in multiple states and countries. Children go away together, connect with peers who understand their experience, engage with nature, and receive emotional support in a community setting. The therapeutic value of being surrounded by others who truly understand is profound.

Goal Writing and Measuring Progress

One question that comes up frequently is how to write measurable goals in this area. The good news is that the framework is not significantly different from other areas of pediatric OT practice. Start with your standardized assessment data — identify the baseline, whether that is sensory dysregulation, regression in ADL independence, decreased attention, or difficulty with peer relationships — and then target the specific functional skill or occupational performance area that has been disrupted.

For example, if a child was independent with dressing prior to the loss of a parent and is now requiring maximal assistance and cuing, that is a documentable regression with a measurable goal. If sensory regulation is significantly impaired and affecting classroom participation, a sensory-based goal tied to the Zones of Regulation is entirely appropriate. Grief as a context does not change how we document; it informs why the regression occurred and guides our intervention approach.

For verbal children, the Pediatric Grief Questionnaire can be re-administered periodically to note changes in emotional expression and engagement. Progress in journaling, participation in group activities, and caregiver-reported changes in home routine and sleep are all meaningful indicators of therapeutic movement.

Conclusion

I began this course by sharing statistics that I believe every occupational therapy practitioner should carry with them: more than six million children in this country are grieving right now, and the consequences of unaddressed childhood grief are serious and lasting. As occupational therapists, we are not just well-positioned to help — we are perhaps uniquely positioned to do so, because our tools are the tools of daily life, of purposeful activity, of play, and of meaning-making.

We have talked today about recognizing the scope and behavioral presentation of children's grief, understanding the DSM-5-TR criteria for prolonged grief disorder, appreciating the cultural and religious diversity that shapes how grief is expressed and supported, and surveying the occupational therapy literature that — while still building — consistently affirms our role. Most importantly, we have explored a wide range of evidence-informed, occupation-based interventions: empathic listening, connecting with nature, mindfulness and meditation, journaling, ADL restoration, the Five Senses Heart Activity, sensory and movement-based activities, art and finger painting, comfort boxes, animal-assisted therapy, and therapeutic use of books and video.

I want to close with something I wrote:

There is a light in every soul that lingers on no matter old.
We hold them close forevermore as their bright lights shine in days and nights.
So close your eyes and feel them near, as they are forever dear.

Grief does not disappear. But with skilled, compassionate occupational therapy, grieving children can learn to carry it — and to keep living, keep playing, and keep growing. That is our work. Thank you for being here.

Questions and Answers

Do you have an example of using finger painting to process emotion?

The most vivid example I have comes from a child whose family member had drowned. The child used both hands — first reaching for the dark black paint, then the blue — and repainted what they imagined had happened to their loved one. And then, unprompted, they drew a boat with their hands. They moved through the trauma of the event and found their own way to a different image. If you really want to get the emotions out, I recommend giving the child the whole hand—not just one finger. The full tactile engagement is part of what makes it so effective.

Are there resources or recommendations for facilitating animal-assisted therapy, or for starting a program?

There are organizations that specifically support this, and they will come out to wherever you are working — a hospice, a school, a clinic. The animals need to be formally trained, and the handler does as well. You cannot simply bring a dog in, even a gentle and friendly one. That sensitivity is important. Pet Partners is one well-established organization; I used them when I worked at Phoenix Children's Hospital. If you have your own pet and are interested in incorporating it, you would need to go through that training process. It is an investment, but it is very, very effective.

Do you have experience working with nonverbal children in this context?

Yes, quite a lot — both specifically around grief and across my years in pediatrics more broadly. With nonverbal children, the sensory component becomes even more central. Address the sensory regulation. Address the sleep, because parents will often tell you the child is not sleeping or is dysregulated at night. If a nonverbal child cannot get an emotion out verbally, they can still listen to a story being read. You can observe the emotion on their face — and that is information. You can offer comfort through blankets, through a stuffed animal, through sensory input. It is worth remembering that 70% of all human communication is nonverbal. We can work with that.

Do you find that ambiguous language around death — crossed over or passed away — is confusing for children?

I have found that it can be, yes. But what I have also found is that children generally understand that the person is gone, because that person is simply not there anymore. When my children were six and eight, and their grandmother died, they heard us use various phrases, and they understood. Now, as adults, they say things like "Grandma passed away." I think the key is not to get too caught up in the language but to focus on giving children ways to still feel connected and find comfort in whatever form works for the family. Some families are not ready to talk about it directly — and that is okay. But more families than you might expect are open to suggestions and grateful for the tools you bring.

At what age do you find prolonged grief to be most prevalent in children?

Honestly, I have seen it most often in adolescents and young adults — roughly eighteen to twenty-two — because that is when there is increasing awareness that grief needs to be addressed, and also because that age group is developmentally more self-aware and emotionally complex. But I want to be clear: a child who lost a parent at age four may not present with prolonged grief until they are fourteen or twenty. If a father died ten years ago and it was never addressed therapeutically, that needs to be part of the conversation now. The statistics around unaddressed grief — suicide, substance use, criminal involvement — are a reminder that delayed intervention is still intervention worth having.

Have you had success billing insurance using prolonged grief disorder as a primary diagnosis?

Personally and professionally, I have not — this has largely been volunteer and passion-project work for me, through organizations like the Forever Family Foundation and the Windbridge Institute. But I genuinely hope that practitioners who take this course can have success with that. The diagnosis is in the DSM-5-TR, it has functional occupational implications, and I believe the field is moving toward greater recognition of this. I hope you will try.

When incorporating meditation into a treatment session, what time frame do you find most effective?

It really depends on the child's age. For younger children and those on the higher-end of the autism spectrum, I typically place meditation at the end of the session, right before they return to their classroom or home, because play is fun and they can get activated during the session, and meditation is a good way to bring them back to a calm state before transitioning. For older children, I often do it at the beginning. Starting with five to ten minutes of mindfulness helps them settle in and emotionally prepare to engage with the art, writing, or video activity that follows. Ultimately, it is up to the clinician to read the child and the session — there is no one-size-fits-all answer here, and that is exactly as it should be.

Can you give an example of a goal you might write to address grief in a child's play or clinical care, and how do you track progress?

This is a great question, and it has come up in the literature as well. The framework is not very different from other goal areas. Start with your standardized assessment data to establish a baseline: sensory dysregulation, regression in dressing or grooming independence, decreased attention, and withdrawal from peer play. Then write a goal targeting the specific functional skill that has been disrupted. If a child was previously independent with dressing and is now requiring maximal cuing, that is a measurable, documentable goal. If attention and cognitive engagement have declined following a loss, that is a goal area too. The grief provides the clinical context; the assessment data provide the measurable baseline. Track progress the same way you would with any occupational performance area — through standardized reassessment, caregiver report, clinical observation, and the child's own expressed engagement and participation.

References

See additional handout.