Dr. Chad Perlyn (Host): Welcome to the For Peds Sake podcast, a Nicklaus Children's Hospital podcast that is all about putting children at the heart of healthcare. I'm your host, Dr. Chad Perlyn, a pediatric plastic surgeon here at Nicklaus Children's and a father of two boys.

Today, we're addressing a very important and sensitive topic, how to talk to children about grief. And to our listeners, you hear I'm already emotional, and I'm going to try to get through this. We had this on the podcast schedule for months, and just last month, the Adler family lost their beautiful daughter, those of you in Miami may know the story, who are listening. She was a beautiful teenager who was lost in an accident. Our family and my children and so many people in this community, so many people in this community and beyond, were so close with Ella and her family. And when Dr. Villani-Capo, who's our psychologist, and I talked about this podcast, whether we should do it or not and whether I would be okay doing it, I decided to. I think it's so important and having just gone through this with my family and my children, this pre-scheduled podcast on this important topic has become so much more meaningful and so much more personal. And I'd like to dedicate this moment to Ella and to her family. And to our listeners, if you hear my tears, they're real, as I think about her. And I'm going to try to get through this with you, Dr. Capo. And we'll let it be what it is, because this is such an important topic. And it's one that we have to talk about. There are tragedies and accidents every day in every community. And I think we need to talk about it. So, thank you for being here for our listeners. And thank you for being here for me today as well.

Dr. Marina Villani-Capo: Thank you so much, Dr. Perlyn. I think you started off this podcast as something that I always recommend, very honest and transparent. This topic is one that is very hard, but I feel so passionate about educating our community and educating our caregivers on how to better address this with our children.

Host: Grief is such a hard topic to handle for adults and each of us handle it differently. Men handle it differently than women. Adults have a hard time with grief and talking about grief, and let alone for our children. Why is it important to talk to children about grief? And should we engage them in these conversations?

Dr. Marina Villani-Capo: I think it's absolutely crucial to talk to our children about grief because they experience grief, too. And as caregivers and as parents, we like to have this vision that will protect them from every situation in life that might be hard. And when life is not as kind and presents us with a situation just like the situation you just experienced with your family, it shocks the system, right? And it's not only the adults that are experiencing this, it's the children, too. And not addressing it and trying to protect our children by not addressing it or avoiding it or try to make them feel like nothing happened, truly, is not the best course of action. We need to address it. We need to teach them how to develop healthy coping mechanisms. And avoiding the subject altogether might cause long-term impacts in their emotional development.

Host: How do parents start this conversation with their kids? Obviously, there's the acuity of a moment of telling your children that something happened. But as we talk about grief and how they're managing grief and dealing with it, how do you have that conversation with your kids? My 15-year-old son was very close with Ella. Do I just one day say to him, "Hey, how are you doing? Are you thinking about her?" What should parents do to help start that conversation?

Dr. Marina Villani-Capo: I think the key is first checking in with yourself. I think a lot of parents and caregivers put so much pressure on themselves not to cry, to keep it together, to be "strong." And in reality, those are not helpful things during this conversation. I think you have to check in with yourself that you're okay having this conversation and having the energy and the effort that it takes to let people go through grief. And I think that's the toughest part, right? We have to let our children go through the process of grief. As a parent, it goes against all your instincts. Every cell in your body is telling you not to do it, but the therapeutic thing is allowing them to have a safe space to go through grief, feeling supported, feeling understood, and feeling that anything that they feel is valid.

There's so many emotions that come with grief. So, I think the first step is checking in with yourself, that you're okay. Having a conversation to start off with, that you're okay being able to answer, "I do not know the answer to that." There's a lot of spiritual and philosophical questions that come up, especially with the older children. So, being okay in sealing your value system with your children during those conversations. So, that's step one.

Step two is doing it in a safe space. You know your children best. So if it's at home, in the family room, surrounded by your pets, if it's at the beach and a walk, it has to be a safe space where they can feel, they can experience those emotions.

And then, the most important thing is not to lie and not to sugarcoat things for children, because again, it goes back to that need of us trying to protect them, but we don't protect them by sugarcoating things or lying. I know a lot of parents might say, "Oh, grandpa was sick and he just went to sleep." That is something we recommend against. We need to be able to feel that we can have the conversation and say, "Grandpa was sick. He passed away. He died. And that means that we're not going to physically see him anymore." And it's heartbreaking. And it's okay if you cry. It's okay that you're expressing and you're allowing your children to see that it's okay to be vulnerable. And that is part of it. You need to be vulnerable. You need to be okay being vulnerable in front of your children.

Host: I think that is really true. And letting our kids see us process is really important. It lets them know it's okay. It's okay to be sad, to feel the loss, and to grieve. I often hear people say that kids grieve differently than adults. Tell us a little bit about that and how kids go through this process so parents can understand.

Dr. Marina Villani-Capo: So, it depends on their age and their developmental stage. Age is very different. You can have a five-year-old that is very aware of their surroundings and their emotional processes, but you can also have a five-year-old, for example, in the autism spectrum or with cognitive delay. So, it really depends on the child and their awareness. But children typically, they go through the stages just like adults, but it goes faster, the stages. So, in the example that I was utilizing about the grandfather passing away, you might tell a child that, he might cry immediately. And two seconds later, he might ask you to play with the dolls. And I have parents coming to me and saying, you know, "Are they okay? I don't think he understood" or, you know, "Is he a sociopath because he didn't, like, process the emotions?" And I always tell parents, it just goes in bursts of time, and the time goes quickly. So, they will be happy one minute, they might be irritable the next, they might cry.

And I think one of the toughest parts, to be honest, in working with families that are grieving and they have younger children, is the children asking again and again what happened. Because children under the age of 10 don't really have that abstract thinking of what permanence is in regards to death. They truly don't understand it. They might view it as a video game that you die and then the character just pops back up, right? So for the adults, it's the hardest because you have to repeat yourself again and again. And for the child, it's what they need and it's what should be done. But I think for us, it's the hardest part.

Host: What are some of the signs that a child, maybe it's a sibling, maybe it's a friend, might be struggling with grief and having a tough time processing what happened?

Dr. Marina Villani-Capo: There are many, many signs, and they vary. And they include changes in behavior, such as withdrawal, aggression, regression to earlier developmental stages. We have kiddos that all of a sudden want to be fed or have nighttime accidents in regards to urine control and bladder control. They might have difficulty concentrating in school or even going to school. Their interest in different activities changes. Maybe they love to go to the beach and all of a sudden they're like, "I don't enjoy that anymore. That's something I did with grandpa," for example, and they don't want to do it anymore. And there's also physical symptoms. And we see it here at the hospital a lot. We start presenting with headache, stomach issues, vomiting, generalized pain. And again, that mind-body connection is so important for us to be aware that sometimes we don't have the right words and our body speaks for us. And for children, we see that a lot.

Host: And so. If those things are physical things, I assume that the pediatrician is the right person to start with. When should parents consider seeking support from a pediatric psychologist like yourself to get kids help? Do they wait until they see signs? Do you recommend early on after a loss? Tell us your thoughts there.

Dr. Marina Villani-Capo: There's different resources, to be honest. And I think it depends on the family and what they're comfortable with. I feel like if a family is comfortable experiencing all the gamut of emotions that come with grief, we always recommend families, they're going to have a hard time the first month, for example, that somebody passes away. Some families want to be proactive and there's different centers like the bereavement center that you can go and be around other people that have lost and are grieving. But for a pediatric psychologist, usually, when they come see me, it's when this changes in behaviors and sleep and appetite and social functioning becomes an impairment. And their school is being affected. Their bodies are being affected. So whenever the caregiver, they're the experts in their children, whenever they know something is wrong, they're more than welcome to reach out even to your pediatrician and they might have a list of providers in the community that specialize in this topic or you can reach out to your nearest children's hospital and seek support.

Host: I'll again share personally my gratitude to you and your team, and in particular your colleague, Sara Rivero-Conil, who was there to help my family and my kids through this tough time in our life. What role do rituals and memorials play in helping children with grief? I know we hear sometimes families are concerned about. Will this re-trigger emotions or set the child back or things like that? Talk to us about these milestone events in the grieving process for a family?

Dr. Marina Villani-Capo: So, when we talk about rituals and memorials, it can be so therapeutic for not only the children, but the family as a unit. This is where your culture, your spirituality, your family values come into play. And they're very important, because it allows the process to be experienced in a way that can provide them with the opportunity to experience what they need to experience, but at the same time experience happy pockets. Like for example, I do a lot of memory boxes with the little ones and even with the older ones, and it's a box where different family members can write letters or experiences with their loved one that has passed away, their favorite colors, maybe like a photograph, their favorite song. And it just allows people to celebrate the person, to remember them, because just because someone passes away doesn't mean that our connection with them is gone. On the contrary, it can keep on going, but just in a different way. And children being able to learn that, just because you don't see something doesn't mean it goes away. It's so therapeutic. And as a family, it allows you to have those moments when you have conversations. You connect with your children. And I always tell people, don't allow grief to separate you. It can be something that can unify you and allow for those communications to just flourish.

Host: What are other specific strategies or activities that parents can use to support their kids through grief?

Dr. Marina Villani-Capo: There's so many tools out there. I love a good book, a movie. I think movies are excellent. There's so many movies right now for children that touch upon the subject. And if you don't find the right words, I always tell parents like, "Let's pick a movie together that talks about the subject. Watch it first." Maybe it goes with your family values and things like that. And allow these things, like the books, the movies, songs, allow that to be a tool to open the door for conversations or even just to experience. You don't even have to have a conversation. Maybe just cry together, laugh together, remember together. These tools are so important to connect people in this experience that's universal, unfortunately. It's a universal experience that children are going to go through. Some children have to go through it earlier than others and it's very sad, and it's heartbreaking. But again, it's an opportunity that we have as adults to teach them how to navigate it and how to live life connected still with these people that have passed on.

Host: Any final advice for parents and caregivers on supporting a grieving child?

Dr. Marina Villani-Capo: Be compassionate and be kind, not only to those that are grieving around you, but to yourself. I think parents put so much pressure on themselves to be perfect or say the right thing or do the right thing. And in these processes, nothing and everything goes at the same time. Be transparent. Allow yourself to experience the emotions with your children. Don't try to hide that from your children. Make sure that you provide yourself a space to grieve yourself, but also to allow other people to help you with it. Tap into your village, into your community, find your resources, ask for help. But again, at the end of the day, it's just about being kind not only to others, that come so naturally, but to yourself.

Host: Marina, Dr. Villani-Capo , thank you so much for being here today. As I said in the beginning, this had been something that we had scheduled as an important topic months and months ago. And it's so much more meaningful to so many of us now who have gone through this. And of course, all our families in the South Florida community who have experienced grief, whether it's the loss of a child or a sibling or a parent for the child, it doesn't matter.

Grief is real, and though the few minutes of advice you gave in this conversation are so important, I think the key message we want our families to take away from this is that help is available. And resources are there, and your team and our psychology team is there for any family in this community that needs help. Please reach out to your pediatrician, to your clergy, and others, and it does make a difference. And the support provided, by not just community and well wishers, but by professionals like yourself, makes a tremendous difference. So, thank you.

Dr. Marina Villani-Capo: Thank you, doctor, for being so honest, and I think this is impactful.

Host: I normally end the podcast with my signature high energy sign off talking about how to find us. Not going to do that today. Instead I'll give one shout out to Ella and to her family and all who love them so much and to all our families across this community who are going through similar situations whether it was a direct relative or a loved one, someone you were close with. And whether it happened recently or far away, it doesn't matter. Huge love and hugs to all. Thank you for listening and just know that Nicklaus Children's is always here for your child and your family. Thanks again, everybody.