When
Children Grieve
Childrens' reactions to death are affected by their age and developmental level, relationship with the person who died, and cognitive understanding of what is happening. Dr.
Vaughan-Cole suggested that "Infants may feel a lack of consistency
in the care they receive if their caregiver dies and may develop a lack of responsiveness due to lack of stimulation. They know something is missing in their care. As children grow older, they begin to deal cognitively and emotionally with loss. Older children understand the concept of permanence and the implications of the death of a loved one on their own lives."
Dr. Vaughan-Cole divides the
signs and symptoms of normal grieving in children into four categories:
*
Considerations of individual temperament
* Physical responses
* Psychological responses
* Complicated grieving patterns
The
child's temperament may dramatically influence the reaction to loss. Temperament will vary with age, and depends on personality, maturity, past experiences, and habits. Different styles of learning also modulate temperament.
Grief
causes profound physical responses in many individuals. Grieving may affect sleeping, eating, bodily functions, fatigue, self-care, and hygiene behaviors. Children may refuse to eat, be afraid to go to sleep, begin losing bladder control, or develop constipation.
Anticipated
psychological reactions such as shock or numbness may develop into extreme sadness or loneliness or escalate into episodes of anxiety or confusion. If the person who died was ill for a long time, older children might express a sense of relief that the person is gone, and then feel guilty about these feelings. Even normal feelings of sadness may deepen into depression. Younger children often begin to
process grief through ritualized behaviors, fantasy conversations with
the deceased, or heightened spiritual feelings.
Children are at a higher risk for adjustment problems when they have had multiple losses, lack a consistent or strong support system, or are dealing with a death by
suicide. Dr. Vaughn-Cole reported that these children may demonstrate a constant, intense, paralyzing wish to be with the deceased. Inability to take care of his or her own physical needs is a clue that a child is not coping. These children have often had a previous history of marginal adjustment and should be evaluated for progression into major depression.
Strategies
to help grieving children are similar to strategies for adults, but they must be more deliberate, more specific, and age-appropriate. Children should be reassured that what they are feeling is a normal grief response, and that they do not have to forget their loved one. Children should be encouraged to talk about what is happening and to share their feelings. Rituals such as saying prayers, writing or
talking to the loved one, or going to the cemetery may be helpful. Older children might read books about loss that will help them realize other people have the same feelings they are experiencing.
New
grief responses may surface as children are confronted with new
developmental tasks and reach new developmental stages. For example, as
children grow older and move toward greater autonomy and independence,
they may again struggle with feelings of loss or abandonment. These feelings may limit them in making changes to greater independence, such as going off to school. Referral to professionals or self-help groups may be warranted for children with prolonged grief responses.
When
Children Die
Cindy Squire, MS, APRN, and Patty Dulle, MSN, APRN, from the University
of Utah College of Nursing, Salt Lake City, Utah,
Children
who know they will die soon face many common fears:
*
Losing control
* Making others sad and lonely
* Imposing on or causing hardships for others
* Being unable to perform
* Suffering and pain
* The unknown
* Absence of an afterlife
* An afterlife of punishment and retribution
* Being alone
* Taking leave of others
* Being forgotten after death (especially common among
adolescents)
Parents and family members can reassure their dying young loved ones that
their feelings are accepted. Offer love, physical closeness, and physical comfort. Parents can talk with children about death in an honest, specific way and give children an opportunity to make decisions about care whenever possible. These strategies are particularly important when the patient is an adolescent.
Some
specific suggestions for parents caring for dying children follow:
*
Require the child to follow reasonable family rules and
behavioral expectations
* Include siblings and pets
* Continue to participate in social events and family
celebrations
* Keep the child near the center of family activity in the
home
* Engage in activities that might otherwise have been
postponed or
neglected because of the child's illness
Communicating
with the family of a dying child presents special
challenges. The healthcare provider should be available when the parents
want to talk about diagnosis, early treatment options, periods of
remission or relapse, and terminal care. The period of bereavement is
especially important because parents need to work through and understand
the death with those who cared for their child. Many parents have
separation issues with the staff, and express a sense of isolation when
everyone seems to go away and leave them alone after the child dies.
The
death of a child forever changes the relationship between parents.
Sexual problems, feelings of guilt, and criticism of each other may lead
to reliance on drugs or alcohol or rejection of one's spouse. Surviving children may feel both neglect and jealousy and require reassurance that these feelings are common.
Grief
has its limits. When people care for dying children, they may feel
compassion fatigue. Parents, family, and caregivers must acknowledge
feelings of burnout. They need to connect with other people who share
their experiences, and they need to talk about what they are feeling.
All need to replenish themselves in order to remain effective in meeting
the needs of the dying child.
Some
resources to help patients or providers care for dying children
include:
*
Candlelighter's Childhood Cancer Foundation: 800-366-2223
* Children's Hospice International: 703-684-0330
* Compassionate Friends: 630-990-0010
* Parents of Murdered Children: 513-721-LOVE
* Pregnancy and Infant Loss Center: 612-473-9372
* Ronald McDonald House: 212-639-0100
References
1.
Vaughn-Cole B. A child's grief: how children deal with
grief.
Program and abstracts of The American College of Nurse Practitioners
National Clinical Symposium; September 28-October 2, 2000; Salt Lake
City, Utah.
2. Squires C, Dulle P. End-of-life care for children.
Program and
abstracts of The American College of Nurse Practitioners National
Clinical Symposium; September 28-October 2, 2000; Salt Lake City, Utah.
3. Vaughn-Cole B. Suicide: psychological and physiological
assessment of grief. Program and abstracts of The American College of
Nurse Practitioners National Clinical Symposium; September 28-October 2,
2000; Salt Lake City, Utah.
