Linda Arbiter, MA, MFT - Building healthy relationships one day at a time!
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.