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by Howard S. King, MD with Ruth E. Freeman, MSW
Parents periodically share with us that there has been a
death in the family, for example, a grandparent. Ruth Freeman,
MSW, Program Director of The Cove Center for Grieving Children,
points out that there are many more grieving children in schools
and communities than people realize. Children sometimes display
symptoms of grief or complicated grief, and yet are diagnosed
as anxious, oppositional or hyperactive. In fact, they may
not have had the opportunity to express feelings directly
about the experience of loss.
Pediatricians should consider that unrecognized grief may
be the reason for unexplained, difficult behavior in the child.
Increasing our vigilance at times of grief may also provide
useful preventive opportunities.
How can we help their young child cope with loss when there
is a death in the family?
At such times, we physicians may feel we need to produce
quick answers, and may be reluctant to go beyond the specific
question when parents ask how they can help their child. As
one colleague said, “There is so much pressure within
the health care system these days to be brief.” But,
when we do that, we may miss opportunities for useful interventions.
There are consequences when we are brief in our answers to
appropriate questions from families seeking guidance. When
we do not assess further, we could end up spending much more
time later, if concerns develop into full-blown parenting
problems.
What should pediatrician be aware of when there is a death
in the family? How can pediatricians engage parents in helping
their children develop resilience through the childhood experiences
of loss?
Grieving is a family experience
One question we should consider is, “How are the parents
doing?” If it was the mother’s mother who died,
how is she coping with the death of her mother? Is she grieving
appropriately? Perhaps their relationship was
complicated, even hostile at times, which might make it more
difficult for the child’ mother to cope with the loss.
Or, if the mother is comfortable doing so, we might ask whether
she would be interested in talking about how things have been
going for her recently. We might ask if she could tell us
something about her mother, some of her memories. If that
is difficult for her, or for us, we might prefer to make a
timely referral to a health care professional or self-help
organization for bereavement support.
Such supportive inquiry can help parents identify strong
emotions that naturally arise at times of loss. Pediatricians
can then help parents to consciously choose how to nurture
their children and manage their own stress and grief.
Anniversary reactions
It may be useful to ask parents if they might have experienced
a major loss when they were children. Sometimes, a mother
who finds it difficult to help her child cope with grief may
have memories of being overwhelmed herself when she was a
young child. Or a father might recall being unsupported when
the death of an important relative was treated as a secret,
or his parents might have had a complicated grief reaction
of their own.
If the pediatrician or other health professional is able
to help the parent talk about those early experiences and
memories, it can be very supportive to the parent, and may
help them to be more available to the child.
Helping the child talk about the loss
It is worthwhile for parents to let the child express his
or her ideas about what happened when a grandparent (or other
close relative) died. For example, the child may wonder, if
she had been a “better” child, this might not
have happened to her grandma. Is the child worried about what
might happen to her parents? Might she “lose”
them, too?
Such ideas and worries may have less impact on the child’s
emotional well being if he or she can talk about them with
a parent or other caring adult.
Talking with children about death
Although children think about death differently depending
on their age, most young children need adults to keep information
concrete and simple, and to tell the truth.
Useful language to use when children ask questions is that
“dead” means that the ears don’t hear, the
eyes don’t see, the skin doesn’t feel, the nose
doesn’t smell, the heart doesn’t beat. Otherwise,
it can be very disturbing to think about Grandma’s body
in a coffin.
It is best not to use phrases like “Grandma is sleeping”
or “We lost Dad” or “Grandpa went to Heaven.”
Children take these comments literally, so they may ask literal
questions like, “If Grandpa went to Heaven, why doesn’t
he come back?” “If we lost her, why don’t
we look for her?” Parents’ responses to children’s
questions about the permanence of death may be interwoven
with their religious beliefs.
Some children will be satisfied with the simple explanation
that a beloved relative has died while others may persist
with curious or anxious questions about death. The pediatrician
can play an important role in explaining to school aged children
how the body stops working, for example, using simple terms
to explain what happens when a heart is too sick to continue
to beat, or what a “stroke” is.
Children’s grieving may show up as irritability or
refusal to engage in certain activities associated with the
family member. Adults will need to pay attention to children’s
grief when it is expressed, even when the timing is inconvenient
or when the child’s behavior may be socially inappropriate.
The pediatrician can offer guidance and reassurance to families
where a child is particularly distressed by a death, immediately
or several weeks or months later.
It is useful to let parents know that children grieve differently
from adults. Children may go out to play minutes after hearing
about their grandmother’s death, but two months later,
a trip to a familiar restaurant may recall a memory that brings
the child to tears.
The child and the funeral
What are the parents’ intentions about the funeral?
Should they take the child to the cemetery? Increasingly,
with appropriate preparation, most parents do. Children can
be told what to expect at a funeral and burial, and may have
a strong wish either to attend or stay home. If possible,
children’s preferences should be taken seriously.
It will be helpful for parents to ask a close relative or
family friend, who knows the child well, to be available during
the funeral to tend to the child’s needs. For example,
the child may want to leave the room, or ask questions, at
times when the parents are not emotionally available to the
child.
It is important for parents to be able to engage in their
own healthy grieving process. The child will not be “hurt”
by witnessing the parent “break down,” as long
as the child can see that the parent is getting support from
other adults, and the child is helped to understand that it
is not his or her job to meet the parent’s primary needs
for support.
The spouse
While the spouse of a bereaved parent may take on the responsibility
for the care and comfort of the bereaved parent and also the
children, it may be that the death of an in-law is a significant
loss for him or her as well.
The spouse may also experience an anniversary reaction derived
from memories of her or his own earlier losses, which might
not have been acknowledged at the time. The pediatrician can
reach out to both parents at the time of a death in the family,
involve both parents in discussion and encourage a dialogue
between them.
Coping with loss begins before a death in the family
In early childhood, there are preparatory opportunities for
parents and children to accept loss as a normal developmental
process. For example, helping children sleep through the night,
in their own bed or crib, can be a constructive developmental
challenge. Similarly, helping the child give up breast-feeding,
the bottle or pacifier may also provide experiences of mastery
and resilience related to loss. The same lessons apply to
the loss of the child’s favorite toy or the death of
a family pet.
Sometimes, these events may come to light when a parent asks
the pediatrician about what is “normal.” In fact,
the pediatrician has a sensitive task at such times. Our challenge
may be to try to understand if there is an underlying worry.
The parents may have difficulty helping the child master these
tasks because they bring back painful memories from their own childhoods. Allowing parents to share those feelings
may make it easier for them to help their children work through
loss more successfully.
Unacknowledged grief in the pediatrician
Of course, physicians and other health care professionals
also have their own experience with bereavement, and may have
unresolved issues with unacknowledged grief. Helping parents
and children cope with loss may stir up feelings that can
get in the way of reaching out to others. If we become aware
of changes in our ways of responding and helping at such times,
it may be useful to talk it over with trusted friends or colleagues.
An example occurred with a physician friend who, at age five,
was fully aware that his father was undergoing life-threatening
surgery, an experience that profoundly affected him and his
family. As an adult, he felt that death was always “just
around the corner.” A few years after he married, his
wife developed a serious although temporary illness.
Shortly after, he began to repetitively lose his keys, wallet
and important papers.
In time, he sought professional counseling and came to understand
how his wife’s illness had stirred up memories of how
anxious he and his family had been when he was five years
old, which he had never had the opportunity to talk about.
By understanding those connections and sharing those experiences
with a compassionate listener, he became more effective in
helping patients and families deal with their own experience
of loss.
Summary
- If parents ask you how to help their child cope with the
death of a grandparent or other close relative, consider
the impact of the loss on the parents as well.
- Helping parents cope with loss will benefit the child.
- Encourage parents to talk about the meaning of the loss.
- A parent may be overwhelmed by a current loss because
it may bring back memories of a previously unacknowledged
loss.
- Remind parents about the importance of providing uninterrupted
time for their child to talk about the death of a family
member.
- Keep things concrete, simple and truthful when talking
about death with the child.
- How children grieve will vary with their age and can
be very different from how adults grieve.
- It does not hurt the child to witness a parent grieving
and receiving support from other adults.
- The spouse of the bereaved parent may also be experiencing
grief, perhaps derived from his or her own previous losses.
- The child’s normal process of growth and development
provides opportunities to cope with loss. Pediatricians
can help parents to understand the value and significance
of such experiences.
- Pediatricians may have their own experiences of unacknowledged
grief. Being aware of such experiences may facilitate the
pediatrician’s ability to be helpful to patients and
families.
Resources
The Hope Program
The Hope Program is a service of the Pediatric Department
of Newton-Wellesley Hospital, supporting parents, caregivers
and children as they attempt to deal with the death of a loved
one. The program also assists pediatricians when a family
under their care experiences loss.
A special bag with play and educational materials for children
ages four through ten, includes a pamphlet for parents and
is available to Hospital services including the emergency
department, oncology, pediatrics, etc. It includes an activity
book to help children explore their own emotions through creative
expression about what happens when someone dies.
The guide for parents advises that “children have the
capacity to mourn beginning in infancy,” and goes on
to suggest guidelines to help parents respond to their child
when he or she is going through the grieving process.
Parents or professionals can contact Lori Stacks at 617-243-6510
to receive Hope Program materials and information.
The Children’s Room
This center for grieving children and teenagers “offers
hope and quality of life to bereaved children and those who
are part of their lives.” Trained, committed volunteers
facilitate groups that meet twice monthly, for children
three to eighteen years old and their families.
The Children’s Room is located at 819 Massachusetts
Avenue, Arlington, Massachusetts 02466. The telephone number
is 781-641-4741.
The Wellness Community
The Wellness Community offers programs to provide support
and education for children, ages five through twelve, who have
a parent or grandparent with cancer. It is located at the Echo
Bridge Office Park, 1039 Chestnut St., Newton Upper
Falls, Mass. 02464. The telephone
number is 617-332-1919.
Web sites
The Cove
www.covect.org
Safe Harbors for Grieving Children serves children and
families in Connecticut and provides useful online information
and guidance, as well as links to children’s bereavement
support organizations in other locations. Books for children
are recommended, including When Dinosaurs Die: A Guide
to Understanding Death by Laurie K. Brown, Children and
Grief by William Worden, and Guiding Your Children Through
Grief by Mary Ann and James P. Emsweiler, founders of The
Cove.
The Centering Corporation
www.centering.org
Offers an extensive catalog of books and materials for
children and adults who are coping with many different kinds
of loss.
The Dougy Center
www.grievingchild.org
P rovides supportive and educational material on line for
children and parents.
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