- Email: [email protected]
When children face death in a family
. When Children
Face Death in a Family
Darlene E. McCown,
.
PhD, RN, PNP
Death affects all family members, including children. Nurse practitioners can help children deal with death by working through their parents. Parents need an understanding of children’s concepts of death; these concepts vary with age and are closely related to developmental concepts, such as object permanence, egocentrism, syncretism, and causality. Practical suggestions of value to the practitioner include (a) formulating a family genealogic chart that includes the deceased person; (b) use of a structured interview guide to gather information about the child and death; (c) special tagging of charts as a reminder, keeping a file of deceased persons, and sending cards to the family on anniversary occasions; (d) scheduling follow-up visits about a year after the relative’s death to review the grief process; and (e) making referrals to community support groups and individuals as needed. J PEDIATR HEALTH CARE. (1988). 2, 14-19.
D
eath touches everyone, even children, and health care professionals assume a major role in events surrounding death. Nurses in particular become involved in assisting family members through the adjustments of terminal illness, death, and grief. The nurse practitioner needs knowledge of children’s understanding of and common reactions to death to support grieving children directly and indirectly by teaching parents how to help their children. CHILDREN’S
n
DEATH CONCEPTIONS
For children death is a part of life. They deal with death in a matter-of-fact manner, learning about it just as they learn about dogs, cars, and new shoes. However, death is a complex concept consisting of both cognitive and emotional components gained through experience with death: Cognitive level + emotional reaction = death concept
Children’s understanding of death changes and generally corresponds to age because age and cognitive level are closely related. Children’s views of death can be categorized into three main age groupings: (1) less than 5 years, (2) 5 to 9 years, and (3) 10 years and older. Birth to 5 Years
The very young child less than 2 years old is fiequently described as lacking awareness of death Darlene E. McCown is Director of the Graduate Program Nursing, Azusa Pacific University, Azusa, California. Reprint requests: Darlene E. McCown, Program, School of Nursing, Azusa Azusa, CA 91702.
14
of the School of
PhD, RN, PNP, Director-Graduate Pacific University, Citrus & Alosta,
(Nagy, 1948). However, Maurer (1961) suggested that a child’s awareness of death begins extremely early with the first physiologic struggles to overcome lack of oxygen. Maurer contended infant sleep-wake patterns and “peek-a-boo” games reflect infant awareness of states of existence and nonexistence. For children between 3 and 5 years of age, death is seen as departure or sleep and is associated with lack of movement. Death is not final, but temporary. Children this age believe death is reversible (Lonetto, 1980; Nagy, 1948). Such children think the dead live on under new circumstances and they attribute life processes such as seeing, hearing, breathing, and consciousness to the dead. Drawings of children 3 to 5 years of age reveal they perceive death as male in gender (Lonetto, 1980). In addition, these children frequently associate death with old age. Ages 5 to 9 Years
Children 5 to 9 years of age think in terms of concrete perceptions and develop generalizations based on observable facts. They attribute specific characteristics to death (Nagy, 1948), giving it trait descriptions such as scary, dangerous, and mean. Death is thought to come in the night and take one away and frequently is associated with the old and the ill, perhaps because they are unable to fend off the one who comes. Death is ofien identified with the dead object rather than as a bodily process resulting in cessation of life. These children correctly identifjr particular biologic aspects related to death, such as heart and lung activity, and ofien focus on concrete specifics of burial and graveyards. School-aged children fie-
quently link death with external forces and violence. JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health
When Children
Care
Ages 9 to 12 Years
By 9 to 10 years of age, the child views death as inevitable and universal (Anthony, 1940; Nagy, 1948; Safier, 1964), a lawful, and final, process that occurs in every person. These young people show feelings of sadness, loneliness, and fear related to death (Maurer, 1961; M&own, 1970). Death is associated with pain as well as disease. Drawings done by children between 9 and 12 years of age show a progression of thought by the use of symbols and colors to express ideas about death (Lonetto, 1980).
F
or children between 3 and 5 years of age, death is seen as departure or sleep and is associated with lack of movement.
Adolescence
Some theorists believe that a true understanding of death and mourning cannot occur until the young person has experienced separation and independence from the parents (Nagera, 1970). The teenager experiences marked physical and psychosocial changes and such periods of rapid change often are times of increased vulnerability to fears and loss. Awareness of death is especially acute at this age (Alexander & Alderstein, 1958; Kastenbaum, 1986). Adolescents hold an immediate view of the future that may contribute to making death a forthcoming, fearful event (Kastenbaum & Aisenberg, 1976). Like adults, teens understand death as a final, universal, and personal experience (Corr & McNeil, 1986). n DEATH AND COGNITIVE DEVELOPMENTAL CONCEPTS
Cognitive developmental concepts offer further insight into the child’s understanding of death. The writings of Piaget provide a basis for these concepts. Object Permanence
Object permanence means children realize that objects continue to exist while outside their perceptual field. This ability develops in the period described by Piaget as sensorimotor and by Erikson as trust vs mistrust. Consistency of the environment, which includes caretakers, assists children to develop a sound basis for a sense of personal existence and object permanence in their world. These cognitive processes usually begin to appear at approximately 8 months of age and are developed by the age of 2 years. For the infant, objects not perceived do not exist. Death,
Face Death in a Family
15
the ultimate separation from an object, has no special meaning for the young infant. However, after the development of object permanence, a sense of separation and searching for the departed object occur. This separation is a painful experience and results in a desire for and clinging to the beloved object (Bowlby, 1960). Egocentrism
The child is considered egocentric until approximately 7 years of age. This is shown by confusion in separating one’s own thoughts from those of others. The egocentric child views death from his or her unique perspective. Children understand death as it directly involves them in the loneliness of separation because of hospitalization, loss of attention, or alteration in normal routine. The child’s reaction might be labeled “self-centered” but is appropriate when considered from an egocentric perspective. Syncretism and Juxtaposition
Syncretism reflects the connectedness of all events and perceptions experienced by children. When children are younger than 7 years old, their perceptions of death become conglomerated into a wholesyncretized. Children are unable to distinguish and separate events, experiences, and places. This concept may explain children’s fears of doctors, nurses, hospitals, and pain because of their association with death. In contrast to syncretism, there is an opposing force called juxtaposition. This type of thinking allows children to conceptualize events as separated from one another-side by side. Again, for persons younger than 7 years old, someone may die and be buried but those two events may not be connected in their minds. This kind of thinking enables children to see death as temporary and reversible.
C
hildren 5 to 9 years of age think in terms of concrete perceptions and develop generalizations based on observable facts.
Causality and Artificialism
Children younger than 7 to 8 years old cannot consider events as occurring by chance. Piaget discovered that children between 5 and 9 years old are bewildered about death and search for the causes. Children cannot believe death occurs by chance. Something must make things happen; thus something makes people die. They may ask: “Did God do it?” or ‘Was
16
McCown
it something I said or did. 2” Children engage in magical thinking and believe their thoughts influence the external world. This thinking pattern makes them vulnerable to guilt and fears regarding their part in the death. Artificialism reflects the idea that things result from a transcendent act of creation. Children think
Volume 2, Number 1 January-February 1988
things and events are the product of human or divine creation, The parent is generally this source of power and children might attribute death to a human, perhaps parental, cause or youngsters might believe God caused the death. Children often harbor the secret notion that adults can make the dying person well or even return a dead loved one to life. Anger, dis-
Journal of Pediatric Health
When Children
Care
appointment, and insecurity may result when the dead one fails to return. Children find this difficult to understand and may lose trust in adults or God. n
SIGNIFICANT
LOSSES FACED BY CHILD
A death in the family will influence the behavior and health of child members. Parent Death
Death of a parent is the most significant loss a child can experience. Many studies have demonstrated the harmful repercussions this loss may have on the child immediately and in later life (Birtchnell, 1970; Bowlby, 1960; Dennehy, 1966; Mum-o & Griffiths, 1969; Rosen, 1986).
C hildren
often harbor the secret notion that adults can make the dying person well or even return a dead loved one to life.
The child may interpret a parent’s death as abandonment or as punishment for some misdeed (Arthur & Kemme, 1964). Children’s responses to parents’ deaths may include behaviors reflecting anger, guilt, and apathy. Grieving children often show somatic distress, insomnia, and loss of appetite. However, it is not unusual for children to display no sign of sadness and grief (Schowalter, 1975). This reaction represents a strong need for denying the overwhelming loss the dependent child experiences when a parent dies. Long-term responses to early parental death such as delinquency, adult depression, and psychiatric disorders have been identified (Birtchnell, 1970; Brown, 1966). Johnson and Rosenblatt (1981) draw an apt distinction between incomplete grief and grief that develops as a natural result of maturation and experience. Later grief behavior that appears in adulthood and is related to the early loss of a parent may reflect maturational grief, a new sense of loss associated with new critical stages in life (eg, the birth of a child or graduation events). Grandparent
Death
A common loss experience children have is the death of grandparents. Very little research has been done in this area. However, children’s literature addresses the topic in several excellent books: Charlotte Zolotow’s My Granhon Lew, Joan Fassler’sMy Grandpa Died Today, Thomas De Paola’s Nana Upstaiils, Nana Downstairs, and Annie and the Old One by Miska
Face Death in a Family
17
Miles. Professionals can encourage parents to obtain and read these books with their children. Dying Child
Occasionally, a child is the dying person. Research has shown that children sense when their conditions are fatal (Spinetta, Rigler, & Karon, 1974; Waechter, 1971) and it is unwise to hide information from them. Fears of dying children also have been studied and were found to vary with age. Natterson and Knudson (1960) showed dying children younger than 6 years old most feared separation from their mothers. Children between 6 and 10 years of age feared bodily injury, whereas children older than 10 years feared impending death. Some of these fears and anxieties can be overcome by the practice of home care for the dying child. Martinson and associates (1978, 1980) described a home care project that enabled children to die at home without the fears and stressesof modern medical care. Nurse practitioners can encourage and enable families to seek home care for dying children. Sibling Death
The death of a child has profound meaning for surviving children. These children have been described as having behavior problems (Binger, Ablin, Fuerstein, Kushner, & Zoger, 1969; Cam, Fast, & Erickson, 1964; Kramer, 1987). Research (Davies, 1983; McCown, 1987; McCown & Pratt, 1985) has shown surviving children have significantly more behavior problems compared with norms on a standardized test. The problems observed in bereaved siblings include school difficulties, somatic complaints, enuresis, nightmares, loneliness, depression, clinging, crying, confusion, antisocial behavior, and jealousy.
D eath of a parent
is the most significant loss a child can experience.
Children whose siblings have died express a sense of loneliness. They are not only separated from their brothers or sisters but also experience emotional separation from sad, grieving parents. These are serious problems that may interfere with the ongoing life of the child. The surviving sibling’s position in the family becomes readjusted to a new role. This readjustment often takes more than a year. Community sup-
18
port groups are frequently available to help bereaved parents and siblings make the adjustments. n
Volume 2, Number 1 January-February 1988
McCown
ROLE OF THE NURSE PRACTITIONER
The professional can best help the child experiencing a loss by informing the parents about children’s common conceptions and reactions to death as well as encouraging supportive responses. Parents are often hesitant or forget to include the children in the family at the time of death. The practitioner can introduce the topic by asking about the child and by gathering specific information that will help adults focus on the needs and experiences of the children. Specific plans and ideas that help support the child can then be developed from the information received. The Childhood Death Awareness Inventory developed by the author will aid the practitioner in gathering necessary data (see boxed material, page 16). Many of the items in this questionnaire were developed by the author for a model for providing home care nursing for families of dying children (Birenbaum, McCown, & Nunneley, 1986). The tool is a strategy for opening communication about a sensitive topic with the child and family; it moves from specific direct information to questions about the explanation given to the child and expected reactions and concludes by helping the parents identify supportive measures to help the grieving child.
C
hildren often harbor the secret notion that adults can make the dying person well or even return a dead loved one to life.
In addition to the insight gained from discussion of the loss or anticipated loss with the family, some guidelines for nurses in working with grieving children include the following (Benoliel, 1985; M&own, 1984) : . The child should be told about the death as soon as possible in truthful, clear, simple terms appropriate to the child’s level of understanding. . The adults in the child’s world should feel free to cry and to share their feelings of sadness with the child in a controlled manner. . The child should be encouraged to discuss, ask questions, and express feelings about the events and experiences surrounding the death. . A specific pattern of grief behavior should not be imposed on the child. . The care-taking needs of the child should continue to be met by a warm, loving person.
The child should be given a choice regarding funeral attendance. Time with the child and loved adults should be set aside in the immediate days after the death to assure the child of his or her value and importance. Other important people in the child’s life should be told of the death (eg, teachers, dentist, and coaches). The child should be encouraged to resume normal activities after the death. At each new cognitive, developmental level the child will need to review and reinterpret the loss again in light of new growth and understanding.
P
arents are often hesitant or forget to include the children in the family at the time of death.
Long-term follow-up of clients who have experienced a death is meaningful to them. Follow-up could include keeping a file on deceased patients and sending a card or note to the family on the anniversary of the death or on special holidays when the family will be remembering the deceased. A special tag on the chart similar to “allergy” tags can serve as a reminder of the death of an important family member. A genealogic chart of the family including deceased members can also help remind and focus on the relationships of bereaved family members. The fact that the nurse practitioner remembers the deceased person is meaningful to the family and will strengthen the supportive relationship with them. The nurse practitioner might encourage a return visit sometime toward the end of the first year after a significant death in the family. The child’s behavior can be reviewed with the parent. Tools are available to help in determining whether the child’s behavior is within normal ranges. The Child Behavior Checklist (Achenbach & Edelbrock, 1983) is one tool that has been successfully used to measure behaviors in bereaved children (McCown, 1987). Children with prolonged and multiple problems after an experience of loss should be referred to a specialist to help avoid long-term emotional disturbances. The nurse practitioner can help families with children through the grief process after the loss of a loved one. The responsibility of the professional includes preventive care for the emotional support of grieving children. This can be accomplished by teaching par-
Journal of Pediatric Health
Care
ents regarding children’s cognitive understanding of death and their common reactions to it. The use of follow-up care and standardized tools to evaluate behavior and referrals when necessary to child guidance specialists are all aspects of supportive care. REFERENCES Achenbach, T., & Edelbrock, C. (1983). Manualfor child bebatior checklist and revised child behavior profile. USA Queen City Printers. Alexander, I., & Alderstein, A. (1958). Affective responses to the concept of death in a population of children and early adolescents, Journal of Genetic Psychology; 93, 167-177. Anthony, S. (1940). The child’s dzhovey of death. New York: Harcourt Brace. Arthur, B., & Kemme, M. (1964). Bereavement in childhood. Journal of Child Psychology and PNchia*, 5, 37-49. Benoliel, J. (1985). Loss and terminal illness. Numin# Clinics of North America, 20, 439-448. Binger, C., Ablin, A., Feuerstein, R., Kushner, J., & Zoger, S. (1969). Childhood leukemia: Emotional impact on patient and family. New England Journal ofMedicine, 280, 414-418. Birenbaum, L., McCown, D., & Nunneley, C. (1986). Nuvses’ manual forfamily childhood cancer study. Portland, OR: Oregon Health Sciences University. Birtchnell, J. (1970). Recent parent death and mental illness. &itisb Journal of Pq&iatry, 116, 289-297. Bowlby, J. (1960). Grief and mourning in infancy and early childhood. The Psychoanalytic Stuclv of the Child, 15, 9-52. Brown, F. (1966). Childhood bereavement and subsequent psychiatric disorder. Britirb Journal ofpsycbiaq, 112, 1035-1041. Cain, A., Fast, I., & Erickson, M. (1964). Children’s disturbed reactions to the death of a sibling. American Journal qf Ortbopqcbiatry, 34, 741-745. Con, C., & McNeil, J. (Eds.). (1986). Adolescence and death. New York: Springer. Davies, E. (1983). Behavioral responses of children to the death of a sibling. Dissertation Abstracts International, 44, 1060B. (University Microfilms No. 83-19,401). Dennehy, C. M. (1966). Childhood bereavement and psychiatric illness. British Journal of PsycbiatT, 112, 1049-1069. Johnson, I’., & Rosenblatt, P. (1981). Grief following childhood loss of a parent. American Journal of l’qcbotbevapy, 35, 419. 425. Kastenbaum, R. (1986). Death in the world of adolescence. In C. Corr, & J. McNeil (Eds.), Adolescence and death, (pp. 415). New York: Springer.
When Children
Face Death in a Family
19
Kastenbaum, R., & Aisenberg, R. (1976). Tbep:ycbolon?, of death. New York: Springer. Kramer, R. (1987). Living with childhood cancer. In T. Krulik, B. Holaday, & I. Martinson (Eds.) The child and fami[v faiq life-threatening illness (pp. 258-272). Philadelphia: J. B. Lippincott. Lonetto, R. (1980). Cbildven’s conceptions of death. New York: Springer. Martinson, I. M. (Principal Investigator). (1980). Home care fey the child with cancer final report. (National Cancer Institute. Grant CA 19490) Minneapolis, MN: University ofMinnesota. Martinson, I. M., Armstrong, G. D., Geis, D. I?., Anglim, M. A., Gronseth, E. C., Macinnis, H., Nesbit, M. E., & Kersey, J. H. (1978). Home care for children dying of cancer. Pediatrics, 62, 106-113. Maurer, A. (1961). The child’s knowledge ofnonexistence. Journal of Existential Psycbiaq, 2, 193-212. McCown, D. ( 1970). Death and children interviervs [Audiotapes]. Medical College of Virginia. McCown, D. (1984). Funeral attendance, cremation and young siblings. Death Education, 8, 349-363. McCown, D. (1987). Factors relating to bereaved children’s behavioral adjustment. In C. Barnes (Ed.). Recent advances in nursing. London: Longman Group, 16, 85-93. McCown, D., & Pratt, C. (1985). Impact of sibling death on children’s behavior. Death Studies, 9, 323-335. Munro, A., & Griffiths, A. (1969). Some psychiatric non-sequelae of childhood bereavement. British Journal of hybiaty, 115, 305-311. Nagera, H. (1970). Children’s reactions to the death of important objects. The Pycboana&ic Study of the Child, 25. 360-400. Nagy, M. (1948). Child’s theories concerning death. Journal of Genetic Pgzbolom, 73, 3-27. Natterson, J. M., & Knudson, A. G. (1960). Observations concerning fear of death in fatally ill children and their mothers. Psycbosomutic Medicine, 22, 456-465. Rosen, H. (1986). Unspoken Brief: Copin u,itb childhood siblinp loss. Lexington, MA: Lexington Books. Satier, G. (1964). A study of relationships between the life and death concepts in children. The Journal of Genetic PqcboloAv, 105, 283-294. Schowalter, J. (1975). Parent death and child bereavement. In B. Schoenberg, et al. (Eds.) Bereavement, itspgxbological aspects. New York: Columbia University Press. Spinetta, J. J., Rigler, D., & Karon, M. (1974). Personal space as a measure of a dying child’s sense of isolation. Journal of Consultinfl and Clinical Pqcbolom, 42, 751-756. Waechter, E. (1971). Children’s awareness of fatal illness. American Journal of NuninJ, 71, 1167-l 172.
Face Death in a Family
Darlene E. McCown,
.
PhD, RN, PNP
Death affects all family members, including children. Nurse practitioners can help children deal with death by working through their parents. Parents need an understanding of children’s concepts of death; these concepts vary with age and are closely related to developmental concepts, such as object permanence, egocentrism, syncretism, and causality. Practical suggestions of value to the practitioner include (a) formulating a family genealogic chart that includes the deceased person; (b) use of a structured interview guide to gather information about the child and death; (c) special tagging of charts as a reminder, keeping a file of deceased persons, and sending cards to the family on anniversary occasions; (d) scheduling follow-up visits about a year after the relative’s death to review the grief process; and (e) making referrals to community support groups and individuals as needed. J PEDIATR HEALTH CARE. (1988). 2, 14-19.
D
eath touches everyone, even children, and health care professionals assume a major role in events surrounding death. Nurses in particular become involved in assisting family members through the adjustments of terminal illness, death, and grief. The nurse practitioner needs knowledge of children’s understanding of and common reactions to death to support grieving children directly and indirectly by teaching parents how to help their children. CHILDREN’S
n
DEATH CONCEPTIONS
For children death is a part of life. They deal with death in a matter-of-fact manner, learning about it just as they learn about dogs, cars, and new shoes. However, death is a complex concept consisting of both cognitive and emotional components gained through experience with death: Cognitive level + emotional reaction = death concept
Children’s understanding of death changes and generally corresponds to age because age and cognitive level are closely related. Children’s views of death can be categorized into three main age groupings: (1) less than 5 years, (2) 5 to 9 years, and (3) 10 years and older. Birth to 5 Years
The very young child less than 2 years old is fiequently described as lacking awareness of death Darlene E. McCown is Director of the Graduate Program Nursing, Azusa Pacific University, Azusa, California. Reprint requests: Darlene E. McCown, Program, School of Nursing, Azusa Azusa, CA 91702.
14
of the School of
PhD, RN, PNP, Director-Graduate Pacific University, Citrus & Alosta,
(Nagy, 1948). However, Maurer (1961) suggested that a child’s awareness of death begins extremely early with the first physiologic struggles to overcome lack of oxygen. Maurer contended infant sleep-wake patterns and “peek-a-boo” games reflect infant awareness of states of existence and nonexistence. For children between 3 and 5 years of age, death is seen as departure or sleep and is associated with lack of movement. Death is not final, but temporary. Children this age believe death is reversible (Lonetto, 1980; Nagy, 1948). Such children think the dead live on under new circumstances and they attribute life processes such as seeing, hearing, breathing, and consciousness to the dead. Drawings of children 3 to 5 years of age reveal they perceive death as male in gender (Lonetto, 1980). In addition, these children frequently associate death with old age. Ages 5 to 9 Years
Children 5 to 9 years of age think in terms of concrete perceptions and develop generalizations based on observable facts. They attribute specific characteristics to death (Nagy, 1948), giving it trait descriptions such as scary, dangerous, and mean. Death is thought to come in the night and take one away and frequently is associated with the old and the ill, perhaps because they are unable to fend off the one who comes. Death is ofien identified with the dead object rather than as a bodily process resulting in cessation of life. These children correctly identifjr particular biologic aspects related to death, such as heart and lung activity, and ofien focus on concrete specifics of burial and graveyards. School-aged children fie-
quently link death with external forces and violence. JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health
When Children
Care
Ages 9 to 12 Years
By 9 to 10 years of age, the child views death as inevitable and universal (Anthony, 1940; Nagy, 1948; Safier, 1964), a lawful, and final, process that occurs in every person. These young people show feelings of sadness, loneliness, and fear related to death (Maurer, 1961; M&own, 1970). Death is associated with pain as well as disease. Drawings done by children between 9 and 12 years of age show a progression of thought by the use of symbols and colors to express ideas about death (Lonetto, 1980).
F
or children between 3 and 5 years of age, death is seen as departure or sleep and is associated with lack of movement.
Adolescence
Some theorists believe that a true understanding of death and mourning cannot occur until the young person has experienced separation and independence from the parents (Nagera, 1970). The teenager experiences marked physical and psychosocial changes and such periods of rapid change often are times of increased vulnerability to fears and loss. Awareness of death is especially acute at this age (Alexander & Alderstein, 1958; Kastenbaum, 1986). Adolescents hold an immediate view of the future that may contribute to making death a forthcoming, fearful event (Kastenbaum & Aisenberg, 1976). Like adults, teens understand death as a final, universal, and personal experience (Corr & McNeil, 1986). n DEATH AND COGNITIVE DEVELOPMENTAL CONCEPTS
Cognitive developmental concepts offer further insight into the child’s understanding of death. The writings of Piaget provide a basis for these concepts. Object Permanence
Object permanence means children realize that objects continue to exist while outside their perceptual field. This ability develops in the period described by Piaget as sensorimotor and by Erikson as trust vs mistrust. Consistency of the environment, which includes caretakers, assists children to develop a sound basis for a sense of personal existence and object permanence in their world. These cognitive processes usually begin to appear at approximately 8 months of age and are developed by the age of 2 years. For the infant, objects not perceived do not exist. Death,
Face Death in a Family
15
the ultimate separation from an object, has no special meaning for the young infant. However, after the development of object permanence, a sense of separation and searching for the departed object occur. This separation is a painful experience and results in a desire for and clinging to the beloved object (Bowlby, 1960). Egocentrism
The child is considered egocentric until approximately 7 years of age. This is shown by confusion in separating one’s own thoughts from those of others. The egocentric child views death from his or her unique perspective. Children understand death as it directly involves them in the loneliness of separation because of hospitalization, loss of attention, or alteration in normal routine. The child’s reaction might be labeled “self-centered” but is appropriate when considered from an egocentric perspective. Syncretism and Juxtaposition
Syncretism reflects the connectedness of all events and perceptions experienced by children. When children are younger than 7 years old, their perceptions of death become conglomerated into a wholesyncretized. Children are unable to distinguish and separate events, experiences, and places. This concept may explain children’s fears of doctors, nurses, hospitals, and pain because of their association with death. In contrast to syncretism, there is an opposing force called juxtaposition. This type of thinking allows children to conceptualize events as separated from one another-side by side. Again, for persons younger than 7 years old, someone may die and be buried but those two events may not be connected in their minds. This kind of thinking enables children to see death as temporary and reversible.
C
hildren 5 to 9 years of age think in terms of concrete perceptions and develop generalizations based on observable facts.
Causality and Artificialism
Children younger than 7 to 8 years old cannot consider events as occurring by chance. Piaget discovered that children between 5 and 9 years old are bewildered about death and search for the causes. Children cannot believe death occurs by chance. Something must make things happen; thus something makes people die. They may ask: “Did God do it?” or ‘Was
16
McCown
it something I said or did. 2” Children engage in magical thinking and believe their thoughts influence the external world. This thinking pattern makes them vulnerable to guilt and fears regarding their part in the death. Artificialism reflects the idea that things result from a transcendent act of creation. Children think
Volume 2, Number 1 January-February 1988
things and events are the product of human or divine creation, The parent is generally this source of power and children might attribute death to a human, perhaps parental, cause or youngsters might believe God caused the death. Children often harbor the secret notion that adults can make the dying person well or even return a dead loved one to life. Anger, dis-
Journal of Pediatric Health
When Children
Care
appointment, and insecurity may result when the dead one fails to return. Children find this difficult to understand and may lose trust in adults or God. n
SIGNIFICANT
LOSSES FACED BY CHILD
A death in the family will influence the behavior and health of child members. Parent Death
Death of a parent is the most significant loss a child can experience. Many studies have demonstrated the harmful repercussions this loss may have on the child immediately and in later life (Birtchnell, 1970; Bowlby, 1960; Dennehy, 1966; Mum-o & Griffiths, 1969; Rosen, 1986).
C hildren
often harbor the secret notion that adults can make the dying person well or even return a dead loved one to life.
The child may interpret a parent’s death as abandonment or as punishment for some misdeed (Arthur & Kemme, 1964). Children’s responses to parents’ deaths may include behaviors reflecting anger, guilt, and apathy. Grieving children often show somatic distress, insomnia, and loss of appetite. However, it is not unusual for children to display no sign of sadness and grief (Schowalter, 1975). This reaction represents a strong need for denying the overwhelming loss the dependent child experiences when a parent dies. Long-term responses to early parental death such as delinquency, adult depression, and psychiatric disorders have been identified (Birtchnell, 1970; Brown, 1966). Johnson and Rosenblatt (1981) draw an apt distinction between incomplete grief and grief that develops as a natural result of maturation and experience. Later grief behavior that appears in adulthood and is related to the early loss of a parent may reflect maturational grief, a new sense of loss associated with new critical stages in life (eg, the birth of a child or graduation events). Grandparent
Death
A common loss experience children have is the death of grandparents. Very little research has been done in this area. However, children’s literature addresses the topic in several excellent books: Charlotte Zolotow’s My Granhon Lew, Joan Fassler’sMy Grandpa Died Today, Thomas De Paola’s Nana Upstaiils, Nana Downstairs, and Annie and the Old One by Miska
Face Death in a Family
17
Miles. Professionals can encourage parents to obtain and read these books with their children. Dying Child
Occasionally, a child is the dying person. Research has shown that children sense when their conditions are fatal (Spinetta, Rigler, & Karon, 1974; Waechter, 1971) and it is unwise to hide information from them. Fears of dying children also have been studied and were found to vary with age. Natterson and Knudson (1960) showed dying children younger than 6 years old most feared separation from their mothers. Children between 6 and 10 years of age feared bodily injury, whereas children older than 10 years feared impending death. Some of these fears and anxieties can be overcome by the practice of home care for the dying child. Martinson and associates (1978, 1980) described a home care project that enabled children to die at home without the fears and stressesof modern medical care. Nurse practitioners can encourage and enable families to seek home care for dying children. Sibling Death
The death of a child has profound meaning for surviving children. These children have been described as having behavior problems (Binger, Ablin, Fuerstein, Kushner, & Zoger, 1969; Cam, Fast, & Erickson, 1964; Kramer, 1987). Research (Davies, 1983; McCown, 1987; McCown & Pratt, 1985) has shown surviving children have significantly more behavior problems compared with norms on a standardized test. The problems observed in bereaved siblings include school difficulties, somatic complaints, enuresis, nightmares, loneliness, depression, clinging, crying, confusion, antisocial behavior, and jealousy.
D eath of a parent
is the most significant loss a child can experience.
Children whose siblings have died express a sense of loneliness. They are not only separated from their brothers or sisters but also experience emotional separation from sad, grieving parents. These are serious problems that may interfere with the ongoing life of the child. The surviving sibling’s position in the family becomes readjusted to a new role. This readjustment often takes more than a year. Community sup-
18
port groups are frequently available to help bereaved parents and siblings make the adjustments. n
Volume 2, Number 1 January-February 1988
McCown
ROLE OF THE NURSE PRACTITIONER
The professional can best help the child experiencing a loss by informing the parents about children’s common conceptions and reactions to death as well as encouraging supportive responses. Parents are often hesitant or forget to include the children in the family at the time of death. The practitioner can introduce the topic by asking about the child and by gathering specific information that will help adults focus on the needs and experiences of the children. Specific plans and ideas that help support the child can then be developed from the information received. The Childhood Death Awareness Inventory developed by the author will aid the practitioner in gathering necessary data (see boxed material, page 16). Many of the items in this questionnaire were developed by the author for a model for providing home care nursing for families of dying children (Birenbaum, McCown, & Nunneley, 1986). The tool is a strategy for opening communication about a sensitive topic with the child and family; it moves from specific direct information to questions about the explanation given to the child and expected reactions and concludes by helping the parents identify supportive measures to help the grieving child.
C
hildren often harbor the secret notion that adults can make the dying person well or even return a dead loved one to life.
In addition to the insight gained from discussion of the loss or anticipated loss with the family, some guidelines for nurses in working with grieving children include the following (Benoliel, 1985; M&own, 1984) : . The child should be told about the death as soon as possible in truthful, clear, simple terms appropriate to the child’s level of understanding. . The adults in the child’s world should feel free to cry and to share their feelings of sadness with the child in a controlled manner. . The child should be encouraged to discuss, ask questions, and express feelings about the events and experiences surrounding the death. . A specific pattern of grief behavior should not be imposed on the child. . The care-taking needs of the child should continue to be met by a warm, loving person.
The child should be given a choice regarding funeral attendance. Time with the child and loved adults should be set aside in the immediate days after the death to assure the child of his or her value and importance. Other important people in the child’s life should be told of the death (eg, teachers, dentist, and coaches). The child should be encouraged to resume normal activities after the death. At each new cognitive, developmental level the child will need to review and reinterpret the loss again in light of new growth and understanding.
P
arents are often hesitant or forget to include the children in the family at the time of death.
Long-term follow-up of clients who have experienced a death is meaningful to them. Follow-up could include keeping a file on deceased patients and sending a card or note to the family on the anniversary of the death or on special holidays when the family will be remembering the deceased. A special tag on the chart similar to “allergy” tags can serve as a reminder of the death of an important family member. A genealogic chart of the family including deceased members can also help remind and focus on the relationships of bereaved family members. The fact that the nurse practitioner remembers the deceased person is meaningful to the family and will strengthen the supportive relationship with them. The nurse practitioner might encourage a return visit sometime toward the end of the first year after a significant death in the family. The child’s behavior can be reviewed with the parent. Tools are available to help in determining whether the child’s behavior is within normal ranges. The Child Behavior Checklist (Achenbach & Edelbrock, 1983) is one tool that has been successfully used to measure behaviors in bereaved children (McCown, 1987). Children with prolonged and multiple problems after an experience of loss should be referred to a specialist to help avoid long-term emotional disturbances. The nurse practitioner can help families with children through the grief process after the loss of a loved one. The responsibility of the professional includes preventive care for the emotional support of grieving children. This can be accomplished by teaching par-
Journal of Pediatric Health
Care
ents regarding children’s cognitive understanding of death and their common reactions to it. The use of follow-up care and standardized tools to evaluate behavior and referrals when necessary to child guidance specialists are all aspects of supportive care. REFERENCES Achenbach, T., & Edelbrock, C. (1983). Manualfor child bebatior checklist and revised child behavior profile. USA Queen City Printers. Alexander, I., & Alderstein, A. (1958). Affective responses to the concept of death in a population of children and early adolescents, Journal of Genetic Psychology; 93, 167-177. Anthony, S. (1940). The child’s dzhovey of death. New York: Harcourt Brace. Arthur, B., & Kemme, M. (1964). Bereavement in childhood. Journal of Child Psychology and PNchia*, 5, 37-49. Benoliel, J. (1985). Loss and terminal illness. Numin# Clinics of North America, 20, 439-448. Binger, C., Ablin, A., Feuerstein, R., Kushner, J., & Zoger, S. (1969). Childhood leukemia: Emotional impact on patient and family. New England Journal ofMedicine, 280, 414-418. Birenbaum, L., McCown, D., & Nunneley, C. (1986). Nuvses’ manual forfamily childhood cancer study. Portland, OR: Oregon Health Sciences University. Birtchnell, J. (1970). Recent parent death and mental illness. &itisb Journal of Pq&iatry, 116, 289-297. Bowlby, J. (1960). Grief and mourning in infancy and early childhood. The Psychoanalytic Stuclv of the Child, 15, 9-52. Brown, F. (1966). Childhood bereavement and subsequent psychiatric disorder. Britirb Journal ofpsycbiaq, 112, 1035-1041. Cain, A., Fast, I., & Erickson, M. (1964). Children’s disturbed reactions to the death of a sibling. American Journal qf Ortbopqcbiatry, 34, 741-745. Con, C., & McNeil, J. (Eds.). (1986). Adolescence and death. New York: Springer. Davies, E. (1983). Behavioral responses of children to the death of a sibling. Dissertation Abstracts International, 44, 1060B. (University Microfilms No. 83-19,401). Dennehy, C. M. (1966). Childhood bereavement and psychiatric illness. British Journal of PsycbiatT, 112, 1049-1069. Johnson, I’., & Rosenblatt, P. (1981). Grief following childhood loss of a parent. American Journal of l’qcbotbevapy, 35, 419. 425. Kastenbaum, R. (1986). Death in the world of adolescence. In C. Corr, & J. McNeil (Eds.), Adolescence and death, (pp. 415). New York: Springer.
When Children
Face Death in a Family
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Kastenbaum, R., & Aisenberg, R. (1976). Tbep:ycbolon?, of death. New York: Springer. Kramer, R. (1987). Living with childhood cancer. In T. Krulik, B. Holaday, & I. Martinson (Eds.) The child and fami[v faiq life-threatening illness (pp. 258-272). Philadelphia: J. B. Lippincott. Lonetto, R. (1980). Cbildven’s conceptions of death. New York: Springer. Martinson, I. M. (Principal Investigator). (1980). Home care fey the child with cancer final report. (National Cancer Institute. Grant CA 19490) Minneapolis, MN: University ofMinnesota. Martinson, I. M., Armstrong, G. D., Geis, D. I?., Anglim, M. A., Gronseth, E. C., Macinnis, H., Nesbit, M. E., & Kersey, J. H. (1978). Home care for children dying of cancer. Pediatrics, 62, 106-113. Maurer, A. (1961). The child’s knowledge ofnonexistence. Journal of Existential Psycbiaq, 2, 193-212. McCown, D. ( 1970). Death and children interviervs [Audiotapes]. Medical College of Virginia. McCown, D. (1984). Funeral attendance, cremation and young siblings. Death Education, 8, 349-363. McCown, D. (1987). Factors relating to bereaved children’s behavioral adjustment. In C. Barnes (Ed.). Recent advances in nursing. London: Longman Group, 16, 85-93. McCown, D., & Pratt, C. (1985). Impact of sibling death on children’s behavior. Death Studies, 9, 323-335. Munro, A., & Griffiths, A. (1969). Some psychiatric non-sequelae of childhood bereavement. British Journal of hybiaty, 115, 305-311. Nagera, H. (1970). Children’s reactions to the death of important objects. The Pycboana&ic Study of the Child, 25. 360-400. Nagy, M. (1948). Child’s theories concerning death. Journal of Genetic Pgzbolom, 73, 3-27. Natterson, J. M., & Knudson, A. G. (1960). Observations concerning fear of death in fatally ill children and their mothers. Psycbosomutic Medicine, 22, 456-465. Rosen, H. (1986). Unspoken Brief: Copin u,itb childhood siblinp loss. Lexington, MA: Lexington Books. Satier, G. (1964). A study of relationships between the life and death concepts in children. The Journal of Genetic PqcboloAv, 105, 283-294. Schowalter, J. (1975). Parent death and child bereavement. In B. Schoenberg, et al. (Eds.) Bereavement, itspgxbological aspects. New York: Columbia University Press. Spinetta, J. J., Rigler, D., & Karon, M. (1974). Personal space as a measure of a dying child’s sense of isolation. Journal of Consultinfl and Clinical Pqcbolom, 42, 751-756. Waechter, E. (1971). Children’s awareness of fatal illness. American Journal of NuninJ, 71, 1167-l 172.