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.
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.
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.
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.
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
Offers an extensive catalog of books and materials for children and adults who are coping with many different kinds of loss.
The Dougy Center
P rovides supportive and educational material on line for children and parents.
Please enter a search term to begin your search.
I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center, and the families of my medical practice.
I hope you find this site useful and encourage any comments.
- Dr. Howard King, M.D.