Children must be supported to grieve: a nurse who has worked across the life spectrum--from neonatal intensive care to hospice care--believes nurses need to support children to come to terms with death and to help them grieve in a healthy way. To do that, nurses must feel comfortable with their own knowledge and skills.

IN THE drama and grief surrounding a death, children can often be forgotten, when a family is grieving. Or, with the best intentions, children may be deliberately excluded. However, children have an amazing capacity to deal with difficult situations, provided they have a supportive environment and caregivers with insight.

Dysfunctional grieving has serious implications on behavior and long-term development of children. As nurses it is necessary, therefore, to understand how children can best be supported during periods of grief. However, in my experience, practicing in both hospice and neonatal intensive care, this is an area with which many nurses feel inadequate or uncomfortable. Many nurses have said they lack the skills and knowledge to provide meaningful advice to the child or their significant others.

It is useful for nurses to realize that a child's developmental stage is a huge factor in how a child will deal with and understand death. Children under three cannot distinguish death from absence; it is reversible. Between three and five years the importance and destructiveness of death is recognized. Magical thinking and fear of death, monsters etc may be a feature. They see death as happening to others. Children of five to nine years recognize death as final and a possibility for themselves. It is associated with injury or mutilation. Death anxiety may be channeled into fantasies. By 12, children know everyone dies, are more realistic in their views, and may ponder the abstract and spiritual aspects of death. (1) These developmental differences affect the needs of the child, and the strategies to be used with a grieving child.

But developmental stage is only one factor in how families will respond to death. Cultural, religious and social attitudes play a significant role. The "religious, political and social attitudes of the person and his group's dynamic cultural life" are also very important. (2)

Maori, traditionally, have a different world view regarding death. Children are generally more involved in the grieving process and death is viewed more as part of the cycle of life.

Exposure to death and prior experience are also important factors influencing a family's approach to death. With smaller families and advances in medical care, we are less likely to be exposed to death. Historically, death in a family was commonplace and children learnt to accept it as part of their normal growth and development. One researcher believes the most important influence on a child's reaction to death is the way parents and other authoritative figures respond to it. (3) Death is increasingly viewed as a taboo subject, adults are often uncomfortable discussing it, and children are thought to need protection from it. This creates fear and anxiety, with fantasy replacing the truth about death.

The media reinforce these feelings. On television death is often violent and dramatic. Cartoon characters suffer varied and gruesome deaths, yet bounce back to fight another round! The same happens in fairytales. Little Red Riding Hood's granny was eaten by the wolf, but later is cut out of the wolf and is still alive. These portrayals make it difficult for children to grasp the realities of death. The use of euphemisms in reference to death such as "he's sleeping", "he's been taken by God", "we've lost him", "passing on", or "he's gone on a long journey", adds to a child's confusion.

The relationship of the child to the deceased is an important consideration too. Experts agree the most disastrous loss is parental death. (4) The child will feel abandoned and experience a myriad of feelings. These may include guilt, anger, fear, disbelief, dismay, insecurity, apathy and sadness. Complicated grief may occur if the child had an ambivalent relationship with the deceased, eg when an abusive parent dies. Grief mixed with relief results in extreme guilt and self-reproach. (4)

Sibling death

Sibling death is traumatic too. Siblings have unique attachments: "they enjoy secrets, schemes, plans and pipe dreams that exclude adults completely". (11) The family changes that occur are usually frightening and bewildering to the other children. Parents are preoccupied dealing with practical matters and their own grief and brothers and sisters may feel excluded, resentful and with inadequate support. Attention-seeking behaviors can result.

Regressive behavior, such as bedwetting, thumb sucking and "clinging" is common and normal. Potentially, if the child is not adequately supported, the behaviors may intensify or persist and can then become cause for concern. When a child's feelings about a loss are ignored or repressed, the absence of reaction can turn into complicated behavior patterns. A number of studies have shown those who suffered bereavement in childhood have a higher incidence of delinquency, Unwanted pregnancy, depression, alcoholism and psychiatric disorders Our grieving patterns are established in childhood. (3) The development of positive attitudes towards death and mechanisms to deal with grief are essential for children, as their adulthood patterns will reflect these. Successful grief resolution, ie achieving emotional detachment from the deceased, is necessary if bereaved children are to be able to make healthy emotional attachments later in life.

The best strategy to facilitate healthy grieving in children is to have them grow and mature, viewing death as part of life. World renowned researcher on death and dying Elisabeth Kubler-Ross says: "This [viewing death as part of life] is in contrast to a society in which death is viewed as taboo, discussion of it is regarded as morbid, and children are excluded with the presumption and pretext that it would be too much for them." (6)

This avoidance of the subject of death has become part of our modern western culture. Society's attitude as a whole is difficult to change, but education targeted to appropriate areas is possible. Emphasis on facilitation of children's grief should be in eluded in nurse and teacher training. Kindergartens and schools can foster positive attitudes toward death by using stories designed for the purpose. Dead pets, animals, insects or plants can be opportunities to discuss death and its implications, both at home and school. Backyard burials for loved pets can provide a learning experience.

When someone is terminally ill, or has died, honesty is essential. A child's fantasy is usually worse than reality, if not given true and age related explanations. An experienced doctor observed: "After 20 years I have never seen any trouble arising from telling the truth and being open and honest. However, I have seen a great many problems when parents try to conceal the truth from their children." (1)

Language used in explanations must be concrete rather than abstract. Using euphemisms, eg "he's gone to steep", or "gone on a journey", causes confusion and will be taken literally. Children become afraid to go to sleep or go on journey, or whatever; themselves. Children must be en courage to talk about their feelings and fears, and be permitted to express both positive and negative feelings about the deceased. Allow them to cry and show sorrow. Accept that, like adults, each child will grieve in a different way. Apathy, or alternating between sadness and periods of happy play, is normal. It is not an indication that the child does not care.

Children need to be enveloped in extra love and security at a time when they feel especially vulnerable. Physical contact is useful. Unnecessary separations should be avoided. Feeling alarmed by the distress and changes within a family, children need to be reassured they will remain safe, and are not in any way responsible for the death which has occurred. Routines and consistency should also be maintained. These strategies help allay fear, guilt and anxiety but should be balanced with allowing children to have space and a way of escaping. Sports, music, play or even solitude can be therapeutic and facilitate acceptance of their feelings.

An important aspect, if children are to eventually achieve emotional detachment, is a chance for them to recognize death has occurred and to say a proper goodbye. Experts concur children should never be forced, but should always be given the choice, to attend the funeral. (2) Seeing the dead body should also be an option. In both cases adequate preparation is needed to reduce the child's stress. This involves prior descriptions of how the body will look and feel, and what form the funeral will take. The child should be encouraged to draw pictures or write letters to the de ceased, which would be placed in the coffin as part of the final goodbye. Taking a child to visit the grave is another way to acknowledge their grief and stimulate further discussion about their thoughts and feelings, as well as giving opportunity to ask further questions.

If these guidelines and strategies are followed grief should be gradually resolved, and disruptive or regressive behavior will eventually reduce. However, children who show excessive feeling or a complete absence of feeling, to frustrating experiences or everyday setbacks two years alter the death, may have buried their grief. Professional therapy could be needed. (7)

Children do grieve and adults need to recognize this and allow them to do so. Lack of understanding and insight into a child's needs during periods of loss can inhibit the grieving process. As a society, we try to protect children and avoid confronting the reality of death. Numerous factors influence a child's reaction to death, including developmental stage, previous related education and experience, the attitude of parents, and the relationship with the dead person.

Children who have suffered loss need re assurance and demonstrations of extra love and security to help them cope with feelings of fear, anxiety and guilt. Openness and honest explanations, and the opportunity to question and express feelings are of paramount importance. The option of attending the funeral and visiting the graveside to say "goodbye" should be given, supported by appropriate descriptions.

By recognizing the special needs of the grieving child and using suitable strategies to facilitate healthy resolution of grief, bereaved children can face a future of stability and emotional maturity.

REFERENCES

(1) Adams, D.W. & Devious, E.J. (1988) Coping with childhood cancer--Where do we go from here? Ontario, Canada: Kinbridge Publications.

(2) Fulton, Robert. (1967) On the Dying of Death in Grollman, Earl A. (ed) Explaining Death to Children Boston: Beacon Press.

(3) Buckingham, Robert. W. (1989) Care of the Dying Child. A practical guide for those who help others. New York: The Continuum Publishing Company.

(4) Dyregrov, A. (1991) Grief in Children: a Handbook for Adults. London: Jessica Kingsley Publishers.

(5) Raphael, B. (1985) The Bereaved Child. Unpublished paper in Book of Readings. Wellington: Open Polytechnic of New Zealand.

(6) Kubler-Ross, E. (1969) On Death and Dying. New York: MacMillan Publishing Company.

(7) Lendrum, 8. and Syme, G. (1992) Gift of Tears: A Practical Approach to Loss and Bereavement Counseling. London: Routledge.

--Jayne Ladbrook, RCpN, BHSc (Nursing),is a duty co-ordinator at Dunedin Hospital