Discussing Death With Children: A Developmental Approach

Sydney G. Kronaizl

Disclosures

Pediatr Nurs. 2019;45(1):47-50. 

In This Article

Supporting the Grieving Child

Grief, as a response to loss, is universal. The ways in which grief is expressed or manifests itself, however, varies greatly among individuals. Subjective though it may be, grief is closely related to one's developmental stage (D'Antonio, 2011; Schonfeld & Demaria, 2016). For this reason, children's grieving will differ dramatically from that of adults. This does not mean children do not grieve, simply that their grieving looks different.

Moreover, as children develop, their own grieving will differ from what it was in the past (Bluebond-Langner et al., 2012; D'Antonio, 2011). For example, in infants, grief may manifest itself in protest, crying fits, despair, and detachment (D'Antonio, 2011). In toddlers, grief may manifest itself in increased tantrums, clinginess, marked shifts in mood, and regression in skills, such as walking, talking, and toilet training (Auman, 2007). Grieving children in these stages especially require a consistent caring presence (D'Antonio, 2011). Therefore, supporting a grieving infant or toddler may include informing a surviving caregiver, who may also be withdrawn and navigating his or her own grief, of the importance of a caring presence and methods to provide this.

In school-aged children, grief may manifest itself in physical sickness (D'Antonio, 2011). As the child's language skills are increasing rapidly, literature interventions may be especially useful to this demographic (D'Antonio, 2011). In general, adolescents possess an understanding of all four aforementioned components of a death concept (Bonoti et al., 2013). As grieving adolescents think hypothetically and become acutely aware of the social implications of the death, walking through ways to answer questions about the death from peers may be especially beneficial (Schonfeld & Demaria, 2016). Manifestations of grief at each developmental stage, as well as recommendations for best practice, are summarized in Table 1.

In supporting a grieving child, particular attention must be given to these developmental considerations. Moreover, one must recognize grief as a physical, emotional, behavioral, and cognitive response to loss (Warnick, 2015). Thus, it is necessary to consider each facet of the response to provide the most comprehensive and beneficial care. Grieving children are in distinct need of an environment in which they feel comfortable asking questions, are able to rely on those around them, and feel safe to grieve openly. The following guidelines can help children feel comfortable expressing and working through their grief. However, these recommendations should not supersede consideration of individual differences among children. In the context of religious and cultural influence, it is important to recognize that one's religious and cultural background will heavily influence his or her conceptualization of death, the afterlife, honoring the dead, and appropriate mourning rituals (Renaud et al., 2013). Moreover, many children are exposed to various cultures, and they may have mixed backgrounds in terms of religious and cultural practices. In these cases, it is important to be aware of this when discussing death with children, and to approach the conversation with the goal of mutual understanding, not ethnocentrism.

Communicate Openly and Honestly

Perhaps the most foundational and empirically supported step in supporting grieving children is including the child in open and honest communication (Schonfeld & Demaria, 2016; Olin, 2016; Warnick, 2015). To achieve this, listen first and take cues from children – allow them to control the pace and content of the conversation. This will grant children the confidence to share their honest reflections and concerns regarding death, instead of participating in a conversation predetermined by the assumptions and preconceptions held by the adult. As Warnick (2015) explains, "Honest and open com munication has consistently been found to help youth who are grieving" (p. 59). That is, having a conversation about death and giving the child the authority in that conversation conveys the message that death is a topic that can and should be talked through. Moreover, in the interest of communicating honestly, there is nothing wrong with not having an answer to a child's question. In these instances, respond honestly that you do not know, and either gather the information required to provide an answer, or direct the question to someone who does know. Some questions, such as "When am I going to die?" or "When are you going to die?" may be shocking or uncomfortable. Although equivocation may be tempting in such instances, it remains necessary to provide as honest and as complete an answer to these questions as possible.

Provide Accurate and Developmentally Appropriate Information

When providing information to a grieving child, it is important to avoid euphemisms or any other language that will have to be corrected or unlearned later. The use of such language can be confusing to the child, and may hinder the child's grieving process and conceptualization of death and dying (Longbottom & Slaughter, 2013). Instead, speak concretely: say "dead" as opposed to "sleeping" or "gone." Additionally, avoid language that will be too difficult for a young child to understand: simplify the true information rather than supplementing or obstructing it with a euphemism. For example, consider a school-aged child whose mother died after going into cardiac arrest. Although this child has an understanding of the importance of the heart for a body's functioning, complicated medical terms may be too difficult to comprehend. In this case, instead of saying, "Your mother had a cardiac arrest and the doctors were unable to resuscitate her; she's gone to rest," explain, "Your mom's heart stopped beating. The doctors tried really hard, but they couldn't get it to start again, so she died" (Olin, 2016).

Be an Emotional Role Model

Death, dying, and grief evoke varied and often unpredictable emotions (D'Antonio, 2011; Olin 2016). When working with grieving children, one can be an emotional role model by assisting them in identifying and validating the emotions they experience in response to the loss. For example, if the child is crying, you may assure him or her that this is okay to cry and encourage caregivers to cry in front of the child rather than concealing it to indicate the same. Additionally, you may highlight to both the child and caregivers the importance of reflecting upon why you are crying, and discussing these reflections with one another. Additionally, one should address feelings of shame and guilt, two common emotional responses to experiencing a death, with the child (Schonfeld & Demaria, 2016). This may look like validating the child's concerns that he or she was in some way responsible for the death, and explaining why that is not the case.

Consider Secondary and Cumulative Losses

When children lose a loved one, they are not only losing the individual, they may be losing shared memories, finances, or a sense of safety and security (Auman, 2007; Schonfeld & Demaria, 2016). If children will be moving somewhere new following the death of a parent or caregiver, they may be losing their nearby family and friends, as well as their established routines. There may also be a secondary loss of the surviving caregiver, who may be grieving or working more hours to maintain the household income. To provide comprehensive psychosocial support to a grieving child, these losses should also be considered, and addressed.

Consider Your Conception of Death

Prior to discussing death with children, it is important to reflect on one's own attitudes toward death to enter the conversation feeling comfortable and informed. Here, preparation is twofold. First, reflect on your own thoughts and feelings regarding death; second, stay up to date on the latest research regarding discussing death with children and supporting grieving children. Doing this allows the adult to become more comfortable with the topic of death and its components, resulting in social cues the child will pick up on (Olin, 2016; Schonfeld & Demaria, 2016). Additionally, consider professional self-care. Identify resources for yourself because you cannot help others if you do not help yourself. Many enter the field of nursing to see their patients lead happy and healthy lives. As such, discussing death with a grieving child can be distressing for both the child and adult. As Schonfeld and Demaria (2016) explain, "Children's grief is often unfiltered and pure; their questions are direct and poignant. It is difficult to witness a child's grief and not feel an effect personally" (p. 2). A child's grief may trigger memories of loss or grieving in the adult. To ensure you are providing the best support to both the child and yourself, monitor your own reactions, thoughts, and feelings when providing support to a grieving child, and only provide what you feel able to. In the event that additional support is needed, don't hesitate to call upon a colleague.

Although the grieving process is highly subjective, and there is no right or wrong way to grieve, there are some recognizable indicators that a grieving child may require additional support. In the context of grief, reactions are extreme and unique, making it extremely difficult to categorize such reactions as normal or abnormal (Schonfeld & Demaria, 2016). However, childhood traumatic grief can be identified as the point at which the trauma of experiencing a death interferes with adaptive grieving in the child (Auman, 2007). Although it is not unusual for a child to withdraw from activities and interactions, to struggle to concentrate, or to become preoccupied with thoughts of death and dying in the immediate aftermath of a death, the persistence of these behaviors or their interference with the child's daily life can be taken as indicators of childhood traumatic grief. In such instances, a referral for counseling services from an appropriate professional may be necessary. A more urgent referral and additional support should be provided in instances where children may pose an immediate threat to themselves or others.

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