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PEDIATRICS Vol. 105 No. 2 February 2000, pp. 445-447
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ABSTRACT |
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Pediatricians should understand and evaluate children's reactions to the death of a person important to them by using age-appropriate and culturally sensitive guidance while being alert for normal and complicated grief responses. Pediatricians also should advise and assist families in responding to the child's needs. Sharing, family support, and communication have been associated with positive long-term bereavement adjustment.
The death of an important person in a child's life is
among the most stressful events that a youngster can
experience.1-3 Adults in the midst of their own grief
often are confused and uncertain about how to respond supportively to a
child.3,4 When the death involves a parent or a sibling,
the potential for an adverse response by the child is
compounded.5 During such a crisis, the pediatrician can be
an important source of education and support for a child and
family.1
By already knowing something of the family interactions and individual
coping skills, the pediatrician is in a position to help evaluate and
understand a child's reactions and to advise and assist the family in
responding to the child's needs.1-3 Awareness of the
child's temperament and typical responses to stress can help the
pediatrician counsel the child and family.2 Cultural and
religious background are important considerations in dealing with the
bereaved family.2,6,7 Knowledge of previous significant
losses and parent and child responses to them are helpful in
understanding and predicting how a death may affect the child and
family.2 Circumstances (eg, prolonged illness, sudden
unexpected death, or violent death) are important additional
considerations.6-8 In instances of disasters with
multiple deaths, the pediatrician is likely to be called on as a
resource by rescue teams, school personnel, and others. The
pediatrician should describe to families and personnel the normal
childhood emotional reactions to such an abnormal incident and offer
support and counsel to the children and to the adults caring for
them.9
The child should be told about a death honestly and in language that is
developmentally appropriate. When advising an adult about informing the
child of the death, the pediatrician needs to be aware that a child's
concept of death varies with age (Table
1) and needs to be able to tailor the
specific advice given to a parent.3,5,10 The family can be
reassured that their showing of feelings, such as shock, disbelief,
guilt, sadness, and anger, is normal and helpful.2 A
bereaved parent or other close family member who shares these feelings and memories (eg, with pictures and stories) with a child reduces the
child's sense of isolation.5,11 Children need reassurance
that they will be cared for and loved by a consistent adult who attends
sensitively to their needs. In addition, they must be assured that they
did not cause the death, could not have prevented it, and cannot bring
back the deceased.1,5,8 Parents should be encouraged to
continue family routines and discipline.2,8,12
TABLE 1
Overview of Children's Concepts of Death
The funeral services can provide even a young child with an important way to grieve a loved one if such involvement is supportive, appropriately explained, and compatible with the family's values and approach.2,8 Children need to be prepared if they are to participate in the funeral process.12 The participation should be tailored according to the developmental level of the child. For instance, the younger child may have the process broken down into shorter, more manageable, intervals. A trusted person should be with a child to explain what is happening and to offer support.3 Older children and adolescents may want to participate by speaking at the funeral or memorial service. Encouraging a child to commemorate loss through some form of participation, such as drawing pictures, planting a tree, or giving a favorite object, will promote inclusion in the process and provide a meaningful ritual.5
Grief for a child is a process that unfolds over time. The initial shock and denial of death may evolve into sadness and anger that can last for weeks to months and eventually end, in the best of circumstances, with acceptance and readjustment.13 Some children may seem emotionally unmoved, thus causing concern to family members.5,8 It is important for the pediatrician to be aware of the range of manifestations of childhood grief (Table 2) and to be alert to prolonged or severe behavior change that signals the need for more intensive intervention.1,4,8 A number of age-appropriate books can be read by or to a child as support for understanding and dealing with the grieving process (Table 3). The pediatrician should remain alert to the resurfacing of the child's concerns at the anniversary of the death, at holidays, or at times of other losses as the child progresses through subsequent developmental stages.5,11
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Recognition of one's own attitudes and reactions to death is essential for objectively and supportively counseling the family.1 Pediatricians must realize that grief counseling is an emotionally demanding, time-consuming, and potentially frustrating endeavor.3 The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version14 identifies diagnoses and conditions and may help the pediatrician evaluate the degree of severity of the child's behavior. Use of DSM-PC coding also may help the pediatrician deal with third-party payers. Referral to a mental health specialist or clergy (pastoral counselor) should be considered when the pediatrician believes that progress is not being made or would feel more comfortable having someone else work with the family.
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RECOMMENDATIONS |
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Recommendation
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COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH,
1998-1999
Mark L. Wolraich, MD, Chairperson
Javier Aceves, MD
Heidi M. Feldman, PhD, MD
Joseph F. Hagan, Jr, MD
Barbara J. Howard, MD
Ana Navarro, MD
Anthony J. Richtsmeier, MD
Hyman C. Tolmas, MD
LIAISON REPRESENTATIVES
F. Daniel Armstrong, PhD Society of Pediatric Psychology
David R. DeMaso, MD American Academy of Child and Adolescent
Psychiatry
Peggy Gilbertson, RN, MPH, CPNP National Association of Pediatric
Nurse Associates and Practitioners
William J. Mahoney, MD Canadian Paediatric Society
CONSULTANT
George J. Cohen, MD National Consortium for Child and
Adolescent Mental Health Services
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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REFERENCES |
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ADDITIONAL READINGS |
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Statement of reaffirmation:
This article has been cited by other articles:
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  American Academy of Pediatrics, K. P. Hymel, and the Committee on Child Abuse and Neglect, and National Association of Medical Examiners Distinguishing Sudden Infant Death Syndrome From Child Abuse Fatalities Pediatrics, July 1, 2006; 118(1): 421 - 427. [Abstract] [Full Text] [PDF]
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D. Markenson, S. Reynolds, and Committee on Pediatric Emergency Medicine and Task The Pediatrician and Disaster Preparedness Pediatrics, February 1, 2006; 117(2): e340 - e362. [Abstract] [Full Text] [PDF]
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J. F. Hagan Jr, and the Committee on Psychosocial Aspects of Child, and and the Task Force on Terrorism Psychosocial Implications of Disaster or Terrorism on Children: A Guide for the Pediatrician Pediatrics, September 1, 2005; 116(3): 787 - 795. [Abstract] [Full Text] [PDF]
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J. Knapp, D. Mulligan-Smith, and and the Committee on Pediatric Emergency Medicine Death of a Child in the Emergency Department Pediatrics, May 1, 2005; 115(5): 1432 - 1437. [Abstract] [Full Text] [PDF]
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 J. R. Kane and M. Primomo Alleviating the suffering of seriously ill children American Journal of Hospice and Palliative Medicine, May 1, 2001; 18(3): 161 - 169. [Abstract] [PDF]
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 O. J. Z. Sahler The Child and Death Pediatr. Rev., October 1, 2000; 21(10): 350 - 353. [Full Text]
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 E. E. Leeuwenburgh Children, Art, and Home Health Care: The Universal Language Home Health Care Management Practice, August 1, 2000; 12(5): 40 - 45. [Abstract] [PDF]
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