DEATH AND ITS IMPLICATIONS

1. DEATH AND ITS IMPLICATIONS ON CHILDREN & ADOLESCENTS

2. Plan of session • Introduction • Death and dying in the 21st century • Encounters with death • Video excerpt • Developmental perspective to understanding death • Factors involved in bereavement • Cascade of Events Model • Resolving grief • The grief of children • Behaviours of grieving children • What children need

3. To Emily To Emily at four death is grandma a Christmas tea party and then no more death is a rabbit an uninhabited hutch and a garden rose growing through its bones death is a bird so many birds die death is a word she follows with WHY So I tell her OLD and I tell her ILL she’s too young for CANCER or MURDER or KILL and heaven at best is somewhere to rest when we’re tired. Emily says yes she can see heaven clearly she can with grandma and rabbit and bird and the leg from the one-legged man (Susan Wallbank)

4. DEATH IN THE 21ST CENTURY • Death has become the taboo subject which previously characterised the subject of sexuality. • Death has been medicalised and is now usually contained to hospitals. Not long ago, death was familiar and usual, occurring in the same household where several generations lived together. • Furthermore, the reduction of infant mortality has nurtured the illusion that death is confined to old age. • The general decline in religious observance, the disappearance of mourning traditions, the breakdown of the nuclear family and a deteriorating social environment which “sanitises” grief complicates the bereavement process.

5. Thinking about death carries a profound threat: The painful recognition that we are all going to die. • However hard we try to evade it, death must be mourned and grief cannot be dismissed as morbid. • How well we accomplish the fact that we must all some day embrace death will have much to do with whether our children shrink from the knowledge of death or learn from the beginning to see death as part of the whole life cycle. • As much as we intrinsically feel compelled to protect children from death, we simply cannot. Whether we discuss it with them or not, children are aware of death.

6. In fact, death is still very much present in our lives. Daily, 40 children in England and Wales are bereaved by the death of a parent. In the USA, approximately 4% of children under the age of 16 years experience the death of a parent. • Considering that suicide and HIV infection is highest in men within the 25-44 age group (who might well be fathers), it is possible to assume that many children, particularly those in deprived social situations, will experience bereavement in their young lives. • The process of learning about death in childhood is vital preparation for the mature tasks of coping with it. • What we tell children about death should be consistent with what we feel and how we behave.

7. ENCOUNTERS WITH DEATH Children may need to adjust to various unpredictable losses in their lives: • Death of a pet • Death of a sibling • Death of a parent • Death of a close relative • Death of a neighbour • Death of a classmate or class teacher • Their own death The above losses can occur through an accident, illness, old age, chronic conditions, a natural disaster, and suicide.Children may also view death vicariously. In fact, Hayworth (1998) stated that through the media children may see 15,000 deaths before reaching puberty. However, the awareness of death is often lacking, and its implications are usually largely ignored.

8. VIDEO EXCERPT • When viewing this excerpt, what pertinent issues come to mind? • What are Molly’s primary emotions during this excerpt? • Imagine that Molly were 13. What would you expect to be different in the scene with Corinna? • If you were Corinna, what would you have done differently?

9. TAKING A DEVELOPMENTAL PERSPECTIVE TO DEATH • Children’s views about death change depending on the developmental stage they are in. Death education and therapeutic intervention must be tailored to their specific developmental stage. • Applying psychological principles, the developmental view about death is mainly tied to their cognitive understanding of the situation. A child in the egocentric stage of development will be viewing and interpreting the world primarily through an egocentric lens. • Other factors, such as coping abilities, parental attitudes, level of intelligence, previous life experiences, environment and culture will also affect children’s understanding of death.

10. Babies and toddlers: less than 3 years • Babies do not understand the concept of death. Initially they view their caregiver as an extension of themselves. Hence, the world and themselves are one. • Babies are in a symbiotic relationship with their mothers and have the task of differentiating themselves from the surrounding environment. • Gradually, they develop an understanding of themselves in relation to their immediate context. They develop an understanding of “being” (e.g. when awake) and “non-being” (e.g. when asleep). • By the age of 3 months, games such as peek-a-boo provide a safe opportunity to experiment with “being and non-being”. Babies respond with both fear and delight. • When the basic understanding of “being and non-being” is consolidated, toddlers enter into the “disappear and return” phase. They engage in various games and delight in seeing the object re-appear (e.g dropping toys from a highchair). However, they soon start to suspect that really not all things return, and at times they are “all gone” (e.g. lighted match, switch, and bathtub). • Hence, toddlers worry about separation, mainly from their mothers, and enter into a phase characterised by separation anxiety. Hence, for them, dying means separation.

11. Pre-Schoolers: 3 – 6 years • Children view the world from the perspectives of their own experience. Although children may use the words “die” and “dead”, they cannot truly comprehend the concept, both verbally and cognitively (e.g. Jane and her grandmother). • Preschoolers cannot imagine what it is like to die. They believe that even when dead, one still lives. The questions they ask attest to this (e.g. how can grandpa breath underground? Where will he eat?) • At this age, children rely on what they learn from adults, peers, books, and television. Although they do not fully understand the concept, they recognise death as something unique which often arouses negative feelings. • Preschoolers take a matter-of-fact approach towards death because of 2 basic assumptions they make: death is accidental and people die only under certain conditions; and they themselves will not die.

12. Pre-Schoolers: 3 – 6 years • They still believe that death is mainly a separation. Hence, any separation may arouse thoughts of death. Parents can alleviate worries as children cannot differentiate between short and long absences. • At this age, children still believe that death is reversible. In order to understand the finality of death, children have to recognise that they are separate from their parents and that, without them, they could still exist. Preschoolers cannot do this. • Preschoolers need their parents to protect them, so they perceive death as being temporary. The media reinforces this concept, although the parents may highlight the permanence of death. • Magical thinking is characteristic of this age. Hence, when death occurs, children may believe that their words or wishes caused it to happen. Death may be perceived as a punishment for their thoughts (e.g. “you will be the death of me”). • Preschoolers also believe that superficial or irrelevant details may cause death. Preschoolers often mention that not obeying one’s parents may cause things to die. They see the act, rather than the consequences of the act, as causing death (e.g. crossing the road).

13. They also tend to connect events that do not belong together and, if they are missing facts, they will fill in the blanks from their imaginations. • Death may also be associated with darkness, monsters, evil, and sleeping. Nightmares and fear of the dark are common at this age. • This carries implications for working therapeutically with preschoolers, who should be helped to verbalise their guilt-inducing thoughts.

14. Early school age: 6 – 10 years • Mid-childhood children can neither deny nor accept death in their own lives. Hence, they reach a compromise, acknowledging that death is real in an external and distant sense. • 6 to 7 year olds suspect that their parents will die some day and that the same fate might await them. For them, death is not so imminent. Hence, they fear their parents’ deaths rather than their own. They may accept the fact that someone died and that death is final but they do not fully understand the fact that death must happen to everyone, including themselves. • Young school-age children speak less often about death. They become secretive and keep their thoughts and feelings about death to themselves. Possibly, they are still too vulnerable to accept the emotional implications of their new thoughts about death. They are also more tuned into reality. Although death is not much spoken about, death anxiety is greatest in this period of development. Children may fear “catching death”, being mutilated, abandoned, or separated from their parents. Hence, broaching the subject of death with these children is of great importance.

15. Although mid-childhood children are better testers of reality, they still carry an amount of magical thinking. They have a strong tendency to personify death, viewing it as an evil taker that stops life. Whoever can get away will live (e.g. the fairytales of Hansel and Gretel, Sleeping Beauty, and Snow White). • Children, particularly boys, use fantasy life to confront death. Hence they play act war and violence, discussing gory details. They also seek detailed information about death and their bodies, trying to gain a sense of control through their own rational analysis of the situation. • Children begin to develop their own sense of moral judgement. They may try to reason out the meaning of life, heaven and life after death. Children may spend time thinking about who God is and what God will do to them. Parental and societal pressures will have a great impact on their thoughts. • Gradually, young school children accept the fact that death is final, inevitable, universal, and personal.

16. Early adolescents: 10 – 12 years • Early adolescents can better distinguish between animate and inanimate objects. They also stop believing that everything that moves is alive. • Hence, death becomes more abstract and spiritual. It is recognised as personal, universal, and real. • Death can now be understood in relation to the laws of nature. Rather than viewing death as an external power that comes upon them, early adolescents view it as an internal dysfunction that causes life to end. Death now assumes a logical perspective.

17. However, early adolescents are better able to understand the facts surrounding death than they understand the feelings. In fact, while they intellectually recognise that death is final and irreversible, they may continue to view death as a punishment. Early adolescents are also concerned with relationships following death (e.g. who will take care of Grandpa? Where shall we get the money once Daddy has died?) • Early adolescents view death as terrible, horrible, evil, sad, and surrounded by gloom. Furthermore, death is no longer personified. • At this age, fear of suffocation, fear of being buried alive, fear of pain and suffering, and the fear of thinking about their own death replace mutilation and separation anxiety.

18. Adolescence: 12 – 18 years • Adolescents share most adult concepts of death and cope with death in a similar manner. • As death destroys the body, it is particularly threatening for adolescents who are concerned with beauty and strength. With puberty, adolescents discover their changing bodies and realise that the natural progression of aging is possible even for them. Death is thus seen as the natural enemy of their new emerging self.

19. Adolescents are future-oriented. Death is perceived as the instrument through which goals are destroyed. Hence, they question the meaning of life when they understand the nature of death. • Adolescents are in the process of fast change, which is mostly out of their control. They attempt to attain a degree of autonomy by asserting control over an area they perceive as being completely beyond their control. Hence, defiance of death may prompt some adolescents to challenge death at close proximity (fast driving; drugs). • Adolescents do not like making a public spectacle of their sorrow. Hence, they may prefer to mourn in private or with their close friends. An exception may occur when their friends are mourning as well.

20. FACTORS INVOLVED IN BEREAVEMENT • In a study conducted by Winston’s Wish, a summer camp for children who gave gone through bereavement, children were asked what questions concern them, in connection with death and bereavement. The following questions were put forward: • Causes of death • The process of living and dying • The inability of doctors to save people • The appearance of the body after death • Spiritual issues • Grieving feelings • The Cascade of Events model (Christ, 2000).

21. RESOLVING GRIEF John Bowlby believed that a child can resolve losses appropriately when: • The child has had a reasonably secure relationship with the person who has died. • The child receives prompt and accurate information about what has happened. The child is allowed to ask questions, which adults answer as honestly as possible, acknowledging that they do not know the answer if that is the case. • The child is allowed to participate in the family grieving, both publicly and privately. • The child has easy access to a trusted adult who can be relied upon for comfort and a continuing relationship.

22. THE GRIEF OF CHILDREN Grief is not a linear process with well-defined boundaries. Rather it is an amalgamation of overlapping phases that vary between individuals. • When a child grieves, the same acute range of emotions experienced in adulthood will be felt. • However, children may find it hard to identify their emotions, which are often conflictual, and hence find it difficult to express their feelings. • In spite of the many possible factors which have an impact on the quality of grief, each child’s bereavement must be recognised as unique.

23. COMMON BEHAVIOURS OF GRIEVING CHILDREN • Children go through various reactions, which may be immediate and/or delayed. It takes approximately 2 years to resolve grief. The following are the most common behaviours: • Shock and denial: Children go through life mechanically, with shock usually lasting from a few hours and up to a week. Denial can extend longer. If the reality is too difficult to accept, it is pushed away for some time. Denial can provide period of reprieve from an overwhelming sense of loss and abandonment. • Panic: As children tend to be self-oriented, they start to worry about how their needs will be met, especially if a parent has died. They need to be reassured that they will be taken care of.

24. Anger: Bereaved children often feel angry at the person who died and they indirectly express their anger by acting out, at home and at school. They may also feel angry at God, at the surviving parent or at anyone who may have been involved in the death. It is important that they express these feelings. • Guilt: Children may at some level feel responsible for the death, particularly if a stormy relationship would have pre-existed. They may start blaming themselves for the death, even if they are cognitively able to understand that they are not responsible.

25. Regression: Children’s world view is challenged and hence they regress to earlier behaviours to maintain some form of control. Normal routines should be followed to restore a sense of security. • Bodily distress and anxiety: Psycho-somatic symptoms may be present, and they may be similar to those which the deceased person experienced before death. Children may fear that they are dying. Constant reassurance and clarification is necessary to cope with this stage. • Clinging or replacement: Many children become clingy and tearful as they fear that other people they love will die too. The children need to be informed of the whereabouts of significant people in their lives and of any possible separations. Children may also try to find a substitute to fill the void, by seeking the affection of another person. Tell the children that, although no one can ever take the place of the deceased and everyone misses him/her so much, there are many other people who love them.

26. Preoccupation with the deceased: Children may find themselves thinking of the deceased all the time and this may cause them unrelenting pain. Reassure and share memories at a family level, emphasising that running away from the situation will not make it go away. • Hyperactivity and shortened attention span: Some children may become hyper aroused, jumping from one activity to another. They may also find it challenging to concentrate for a length of time. Children need to be provided with structured activities. Teachers should be informed of the death so that they will be able to understand behavioural changes. • Withdrawal: Grieving children may withdraw from people they love, as they are afraid that these people will die too. They may also avoid getting to know new people as they fear hurting again. Explore these fears with the children. Acknowledge the fact that a person can die unpredictably, but that loving a person is worth the risk.

27. Assumptions of mannerisms of the deceased: Bereaved children may start to act or talk like the deceased person. Remind the children that although the dead person was special and they may share some characteristics, you love them just as they are, for their own uniqueness. • Idealisation of the deceased: Children often remember only the good things about the person who would have died. It is not healthy for children to fantasise that the dead person was perfect. This may encourage unrealistic expectations of other people. Emphasise that no one is perfect but we can love them anyway. • Repressed feeling expressed later: When children do not express their sorrow (due to their age or lack of support), they may need to revisit their grief at a later stage in their lives. Something in the future may trigger the feelings which would have been denied or repressed. • Other symptoms: Children may also develop phobias (of the dark; of hospitals; of doctors; of school). They may suffer from depression, nightmares, experience sleeping or feeding difficulties, bite their nails, play with their hair or pick themselves.

28. WHAT CHILDREN NEED • Information: They need to have information prior, during and following the death. This is particularly true when the death is a public event covered by the media. • Explanations: Information given to children should be truthful, sensitive and honest, even if this is hard for the adults concerned. Children’s fantasies might be actually worse than the reality of the death. Explanations should be concrete, clear and understandable. The “drip feed” system can help children in that they have time to evaluate and assimilate the explanations given. • Help in expressing feelings: When adults express their feelings, children will learn what is acceptable and healthy. Children’s reactions to the death should be viewed as part of a healing process, however stressful they might be to the surviving adults. Furthermore, the bereavement process may be complicated when children receive contradictory messages about the way they should behave (e.g. “you have to take care of mummy now”).

29. The funeral: Till some time ago, children were not included in rites of passage. It is now argued that grief is a family and community event, which is resolved better if shared and understood. • Inclusion: Not including children at the funeral may cause confusion, anger and a gap in their understanding of the situation. Children should be allowed to ask questions prior and following the funeral, hence dispelling any myths they might have. • Viewing the body: This is a daunting prospect, even for adults. For children, viewing the body might dispel myths that the person is still alive. However, children need to be informed beforehand about what to expect, even at a sensory level (i.e. sights, sounds, touch and smell). They need to be aware that this is the last opportunity to say goodbye. When the adults are sure that the child understands the significance and the importance of the rite, the child should be allowed to decide, and never coerced. • Attendance at the funeral: As with viewing the body, the child needs to be given information about the process of a funeral service. They should be asked whether they want to say something to the deceased. The child should also be invited to take part in post-funeral gatherings, where the life of the deceased is celebrated. • Reassurance: Following the disruption caused by death, children need reassurance to understand that the world as they know it has not completely disintegrated. They need boundaries and structure to feel safe, with a return to the normal daily routine providing security and reliability. They also need time to explore the new environment in their family caused by the death.

30. Maternity One wept whose only child was dead, New born, ten years ago. “Weep not; he is in bliss,” they said. She answered, “Even so, Ten years ago was born in pain A child, not now forlorn. But oh, ten years ago, in vain, A Mother, a mother was born.” Alice Meynell (1847 – 1923).

31. BIBLIOGRAPHY • Hagan Arnold, J., & Buschman Gemma, P. (1983). A child dies: A portrait of family grief. Maryland: Aspen Systems Corporation. • Jewett, C. (1994). Helping children cope with separation and loss. London: Free Association Books. • Kubler Ross, E. (1985). On children and death. New York: Macmillan Publishing Company. • National Council for Hospice and Specialist Palliative Care (2002). Early bereavement: What factors influence children’s responses to death? London: King’s College. • Smith, S. C. (1999). The forgotten mourners: Guidelines for working with bereaved children. London: Jessica Kingsley Publishers Ltd. • Smith, S. C., & Pennells, M. (1995). Interventions with bereaved children. London: Jessica Kingsley Publishers. • Wolf, A. W. M. (1975). Helping your child to understand death. New York: Child Study Press. http://www.cinematherapy.com/filmindex.html#children • Corina,Corina • Fly Away Home • Ponette • Shadowlands • Terms of Endearment • Unstrung Heroes