childhood bereavement

8/8/2019 Childhood Bereavement

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December 20, 2010

Jen ODonohoe, MD

MORNING REPORT :CHILDHOODBEREAVEMENT


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Models of Bereavement Psychoanalytic Models

Freud viewed children as incapable ofpsychological mourning and felt that thismade them vulnerable to laterpsychopathology

Bowlby felt that children could mourn if: They had a reasonably secure relationship with

both parents before the loss

They received accurate information about whathappened

They were encouraged to ask questions

They had the opportunity to participate in funeralrites

They had the comforting presence of thesurviving parent


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Models of Bereavement Cont.

Blunt Trauma Model

The loss as a discrete blow

Focused on the nature of the event and the developmental age of thechild

Too simplistic and linear Shock-Aftershock Wave Model

Took into account other intervening factors (e.g. what was the quality ofcare received by the child after the loss)

Also recognized that the child continues to experience and re-experience

grief throughout development Cascade of Events Model

This model takes into account the interaction between the developmentalstage of the child, the specific meaning of the parents death, subsequentlife stressors, and the individual childs characteristics


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What is the role of the Pediatrician? According to the American Academy of Pediatrics Committee on

Psychosocial Aspects of Childhood and Family Health:

Pediatricians should understand and evaluate childrens reactions to

the death of a person important to them by using age-appropriateand culturally sensitive guidance while being alert for normal andcomplicated grief responses. Pediatricians also should advise andassist families in responding to the childs needs. Sharing, familysupport, and communication have been associated with positive

long-term bereavement adjustment.


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The Mortality Revolution Advances in medicine and

sanitation have drasticallyincreased life expectancy since thelate 19th century

75% of deaths in the US occur in

people over 65 Death has become invisible and

abstract

Death is often seen as a failure ofmedical treatment rather than the

inevitable and natural end to life


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Cultural Context of Death Mourning customs

Shiva

The Irish wake

Burial rituals

Cremation

Embalming

After the burial

Alter dedicated to the deceased(Japan)

Still part of the community (Gambia) Dangerous spirit (Hopi Indians)


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1-3 Year Olds Question: Mommy, after I die, how long will it be before Im alive

again?

Thoughts: Limited understanding of accidental events, of futureand past time, and of the difference between living and nonliving.Death is perceived as separation or abandonment.

Developmental Understanding: Death is viewed as continuous withlife. Life and death are often considered alternate states. There isno cognitive understanding of death.

*Source: Hurwitz, Duncan & Wolfe, 2004.


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1-3 Year Olds Strategies: Maximize physical

comfort, familiar persons, andfavorite toys. Be consistent. Usesimple physical contact andcommunication to satisfy the needfor sense of self-worth and love.

You are my wonderful child and Iwill always love you.

Manifestations of Grief:Regression, Sadness, Fearfulness,Loss of appetite, Failure to thrive,Sleep disturbance, Social

withdrawal, Developmental delay,Irritability, Excessive crying,Increased dependency, Loss ofspeech


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3-5 Year Olds Statements: Ive been a bad boy, so I have to die. I hope the

food is good in heaven.

Thoughts: Concepts are crude. The child may not distinguishbetween reality and fantasy (magical thinking). Perceptionsdominate judgment.

Developmental Understanding: The child sees death as temporaryand reversible and not necessarily universal (only old people die).Because of egocentricity, the child often believes that he or shesomehow caused the death, or views it as a punishment. Death is

like an external force that can get you and may be personified (e.g.,the bogeyman).


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3-5 Year Olds

Strategies: Correct the childs perception ofillness as a punishment. Maximize thechilds presence with his parents. Helpparents accept and appreciate opendiscussions about how the family will

function once they are gone. Reassure thechild and help parents lessen the guilt thatthe child may feel about leaving by usinghonest and precise language. When youdie, we will always miss you, but we will

know you are with us and that you are in asafe place.

Manifestations of Grief: Increased activity,Constipation, Soiling, Bed-wetting, Angerand temper tantrums, Out-of-controlbehavior, Nightmares, Crying spells


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5-10 Year Olds Questions: How will I die? Will it hurt? Is dying scary?

Thoughts: The child begins to demonstrate organized, logicalthought. Thinking becomes less egocentric. The child begins toproblem-solve concretely, reason logically, and organize thoughtscoherently. However, he has limited abstract reasoning.

Developmental Understanding: The child begins to understanddeath as real and permanent. Death means that your heart stops,your blood does not circulate, and you do not breathe. It may beviewed as a violent event. The child may not accept that death

could happen to himself or anyone he or she knows but starts torealize that people die.


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5-10 Years Old Strategies: Be honest and provide specific

details if they are requested. Help andsupport the childs need for control. Permitand encourage the childs participation indecision making. We will work together to

help you feel comfortable. It is veryimportant that you let us know how you arefeeling and what you need.

Manifestations of Grief: Deterioration ofschool performance caused by loss ofconcentration, lack of interest, lack ofmotivation, failure to completeassignments, and daydreaming in class,Resistance to attending school, Cryingspells, Lying, Stealing, Nervousness,Abdominal pain, Headaches, Listlessness,

Fatigue


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10-13 Years Old Statements: Im afraid if I die my mom will just break down. Im

worried that when I die, Ill miss my family, or forget them orsomething.

Thoughts: Thinking becomes more abstract, incorporating theprinciples of formal logic. The ability to generate abstract

propositions, multiple hypotheses, and their possible outcomesbecomes apparent.

Developmental Understanding: The preteen begins to understanddeath as real, final, and universal. It could happen to him or her orfamily members. The biological aspects of illness and death and

details of the funeral may begin to interest the preadolescent. He orshe may see death as a punishment for poor behavior and mayworry about who will care for him or her if a parent or caregiverdies. He or she needs reassurance that he or she will continue to becared for and loved.


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10-13 Years Old Strategies: Help reinforce their self-esteem, sense of worth, and

self-respect. Allow and respect their need for privacy, but maintainhis or her access to friends and peers. Tolerate their need toexpress strong emotions and feelings. Support the need forindependence, and permit and encourage participation in decision

making. Though I will miss you, you will always be with me and Iwill rely on your presence in me to give me strength.

Manifestations of Grief: Deterioration of school performance,Resistance to attending school, Crying Spells, Depression, SomaticComplaints, Delinquent behavior


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14-18 Year Olds Statements: This is so unfair! I cant

believe how awful this cancer made melook. I just need to be alone!

Thoughts: Thinking becomes moreabstract. Adolescence is marked by risk-

taking behavior that seems to deny theteenagers own mortality. At this age,the teenager needs someone to use as asounding board for his or her emotions.

Developmental Understanding: A more

mature and adult understanding ofdeath develops. Death may be viewed asan enemy that can be fought against.Thus, dying may be viewed by theteenager as a failure, as giving up.


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14-18 Years Old Strategies: I cant imagine how you must be feeling. You need to

know that despite it all, you are doing an incredible job handling allof this. Id like to hear more about what you are hoping for andwhat you are worrying about.

Manifestations of Grief: Depression, Somatic complaints,Delinquent behavior, Promiscuity, Suicide attempts, Dropping outof school


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Tasks for Mourning Understanding what caused the loss

Grieving or experiencing the painful feelings associated with theloss

Commemorating the value of the loss

Going on with life by accepting and integrating the losspsychologically and emotionally within themselves


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What Does a Child Need to be able to Mourn? Talk honestly and openly about the death or illness in language that

is developmentally appropriate.

A safe and secure space in which they can mourn.

Family members showing their feelings of shock, disbelief, guilt,sadness, and anger is normal and helpful.

It is also helpful to share memories (pictures and stories).

Reassure the child that they will be loved and cared for.

Assure them that they did not cause the death, could not haveprevented it, and cannot bring back the deceased.

Family routines and discipline should be continued. The children should participate in funeral services as this can

provide even a young child with an important way to grieve a lovedone.

Participation should be tailored in a developmentally appropriate way.


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Donts for the surviving parent Dont deny the truth when you explain a parents illness or death.

Dont evade youngsters questions concerning their parents illnessor death, but dont inundate them with details for which theyhavent asked.

Dont

gatekeep or allow other family members to keep kids awayfrom a dying parent or from discussions that they fear might upsetchildren.

Dont overwhelm kids with your grief. As you express your angerand sadness, assure them that youll care for them and that you will

survive this loss together. Dont ask kids to take on the role of their deceased parent or to act

like an adult.


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Resources in Utah for Families Family Support Center and Library on the first floor of The

Huntsman Institute

http://www.huntsmancancer.org/pdf/brochures/CRG09.pdf (link toa brochure from Huntsman that has a lot of local resources)

Cancer Wellness House: www.cancer-wellness.org/ I referred my patient to their KIDS Club which for kids whose parents have

been diagnosed with cancer


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Selected Books About Bereavement for Parentsand Children

Young Children and Parents Dealing With Death

-The Dead Bird, by Margaret Wise Brown. Addison-Wesley, Reading,MA, 1958 (3 to 5 y)

-Lifetimes: The Beautiful Way to Explain Death to Children, by Bryan

Mellonie and Robert Ingpen. Bantam Books, New York, NY, 1983 ( 3to 6 y)

-When Dinosaurs Die: A Guide to Understanding Death, by LaureneKrasny Brown and Marc Brown. Little Brown, Boston, MA, 1996 ( 4 to8 y)

-Accident, by Carol Carrick, Seabury Press, New York, NY, 1976 (6 to 8y)


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Older Children and Young Adolescents on Deathof a Sibling or Close Friend

-A Taste of Blackberries, by Doris B. Smith. Thomas Y. Crowell Co, NewYork, NY, 1973 (8 to 9 y)

-The Magic Moth, by Virginia Lee, Seabury Press, New York, NY 1972

(10 to 12 y)

-Beat the Turtle Drum, by Constance C. greene. The Viking Press, NewYork, NY, 1976 (10 to 14 y)

-Bridge to Terabithia, by Katherine Paterson. Thomas Y. Crowell Co.,

New York, NY, 1977 (10 to 14 y)-Straight Talk About Death for Teenagers, by Earl A. Grollman. BeaconPress, Boston, MA, 1993 (13 to 19 y)


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Guidelines for Parents and Other Caregivers

-How Do We Tell the Children? Helping Children Understand and CopeWith Separation and Loss, by Dan Schaefer and Christine Lyons.Newmarket Press, New York, NY, 1993

-Talking About Death: A Dialogue Between Parent and Child, by Earl A.Grollman. Beacon Press, Boston, Ma, 1990

-Sudden Infant Death Syndrome: Who Can Help and How, edited byCharles A. Corr, Helen Fuller, Carol Ann Barnickol and Donna M. Corr.Springer Publishing Co, New York, NY, 1991

-Questions and Answers About Suicide, by David Lester. The Charles

Press, Philadelphia, PA, 1989-Young People and Death, edited by John Morgan. The Charles Press,Philadelphia, PA, 1991


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References

Committee on Psychosocial Aspects of Child and Family HealthThe Pediatrician and Childhood BereavementPediatrics, Feb 2000; 105: 445 447

Talking With Children About Loss: Words, Strategies, and Wisdom

to Help Children Cope with Death, Divorce, and Other DifficultTimes, by Maria Trozzi and Kathy Massimini. The BerkleyPublishing Group, New York, NY, 1999

Healing Childrens Grief: Surviving a Parents Death from Cancer,by Grace Hyslop Christ. Oxford University Press, New York, NY,2000.

Human Development (textbook) by Diane Papalia, Sally Olds, andRuth Feldman. McGraw-Hill Humanities, 11 edition, 2008: 617-637.


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