MENTAL HEALTH
C0:~1TINUI1~1G practicing pediatrician
CHALLENGE for the is
meeting
the needs
of parents, many of whom seem less well prepared for parenthood than for almost any other major undertaking. However, many conscientious parents are persistent in
Death and the
their
questions to the pediatrician and take every opportunity to profit from the professional’s knowledge and expertise relative to the child’s physical or emotional health. Sensitive questions often arise about the beginning and the ending of life. Many contemporary parents talk openly with their children about sexuality, childbirth, and the biologic processes attending the beginnings of life, but have difficulty in discussing the end of the life cycle. Perhaps the major reason for this difficulty is that death education is not found in the school curriculum. Another explanation is that today’s families live in a death-denying society. Memorial services take the place of funerals; people pass away; flowers wither or fade. Real experiences with death have been taken out of the home, to be replaced with violent death as portrayed on television. For example, a two-year-old discovered discarded flowers in the trash and asked his mother why they were there. When his mother replied that they were dead, he wanted to know, &dquo;Who shot them?&dquo; The following statements by Berg and Daugherty epitomize this succinctly:
Young Child
Some Practical on
Support
Suggestions
and
Counseling
Dixie R. Crase, Ph.D., Darrell Crase, Ph.D.†
Not too many years ago, dying and death were very much a natural part of the total family life cycle. Families lived together, often with several generations in the same household. The dying process took place within the family circle as did the death itself and the funeral in many cases. Young people °
* Associate Professor of Child Development, Departof Home Economics, Memphis State University. &dag er; Associate Professor of Health and Physical Education, Department of Health, Physical Education, Memphis State University, Memphis, Tenn. 38152. ment
747
Downloaded from cpj.sagepub.com at Karolinska Institutets Universitetsbibliotek on May 30, 2015
thus enabled
view the processes of and bereavement as natural parts of the total life cycle. This is not true today, because these processes are typically removed from the family experience. In many instances, the act of dying has lost its dignity and normalcy and has become institutionalized, dehumanized, and mechanized-and young people have been excluded from the experience altogether. The resulting void of experience must be filled if society is to retain a proper perspective toward the value of life.’ were
to
dying, death, grief,
Many parents want to shield children and young people from a knowledge of or experience with death. Yet, part of the adventure into life is the understanding of death.
Kastenbaum,
thorities
on
one
death and
of the
dying,
current au-
wrote:
’The Kingdom where nobody dies,’ as Edna St. Vincent Millay once described childhood, is the fantasy of grownups. We want our children to be immortal-at least temporarily. We can be more useful to children if we can share with them realities as well as fantasies about death. This means some uncomfortable moments. Part of each child’s adventure into life is his discovery of loss, separation, nonbeing, death. No one can have this adventure for him, nor can death be locked in another room until a child comes of age.’
A child is entitled
to this phase of his education. Death education is preparation for living.3 An adequate understanding of death is inseparably bound up with the nature and purpose of life.
Expression of Concepts Through Play
of Death
Psychologists are suggesting that death actually begins in late infancy. Children between eight and 12 months of age begin to play such games as peek-a-boo (a name derived from Old English words meaning &dquo;alive or dead&dquo;). Very soon after he learns that some things do not return; they may instead be &dquo;all-gone.&dquo; The young child’s awareness
fascination with the toilet may in part be due the concept of &dquo;all-goneness.&dquo; Perhaps the toddler experiments with experiences of to
separation, loss, realize.
and
nonbeing more than
we
Preschool children often play out their developing concepts of life and death. &dquo;He’s dead; call the doctor quick!&dquo; suggests that preschoolers have not grasped the finality of death. Not until children are about nine years of age do they comprehend the universality, irreversibility, and inevitability of death. Their conceptions of death are then to some extent dependent upon their family’s religious beliefs. Chasing games during this age period are interpreted as death being &dquo;it.&dquo; The adolescent often fluctuates between knowing that death is inevitable and final and believing that it is reversible and 4
escapable.4 These comments suggest that death emucation should become a part of the development of individuals, especially when relevant issues arise. Most pediatricians will have the opportunity to counsel with families during a critical disease or a loss of life, and can counsel them regarding the right words, feelings, and explanations so necessary at those times.
Basic Principles in
Counseling
Some physicians seem to have inadequacies fears in the handling of death.’ Regardless of whether the physician, parent, or someone else is instrumental in the counseling of a child on the sensitive issue of death and dying, certain fundamental prinor
worthy of being pursued:e questions about death truthfully, and directly. First, try to discover simply, what the child is asking or is inexactly terested in knowing. When the young child asks, &dquo;What will happen if Mommy dies?&dquo;, he may be wanting to know &dquo;Who will take care of me?&dquo; Responding to such an inquiry by asking, &dquo;What do you think?&dquo; may give the child the opportunity to clarify his specific concerns. Explanations about death and circumstances surrounding family grief should be simple and nonperplexing. For example, explanations such as &dquo;Grandmother has gone on a long trip&dquo; or &dquo;to die is to sleep&dquo; may be confusing for very small ciples
are
1. Answer
children, and will have those who
are
to
older.
748
Downloaded from cpj.sagepub.com at Karolinska Institutets Universitetsbibliotek on May 30, 2015
be clarified for
Questions about death must be answered truthfully, with answers which can form the foundation for later concept development. This may mean acknowledging uncertainty, differences of opinion, or the mystery of death. Explaining what will happen to a child faced with terminal illness, though Many contemporary parents talk openly with their children about sexuality, childbirth9 and the biologic processes attending the beginnings of life, but have difficulty in discussing the end of the life cycle.
exceedingly difficult for both parent and physician, should be done as simply and reassuringly as possible, yet truthfully. The following comments epitomize this notion rather well. Kubler-Ross, one of the foremost pioneers in these studies, was asked by a dying child, &dquo;Am I going to die~&dquo; &dquo;Yes, you are going to die,&dquo; she replied. The young child continued, &dquo;And when that long, black car [hearse] comes to get me and carries me to the cemetery will you sit beside me and ride to the cemetery?&dquo; Kubler-Ross again replied, &dquo;Yes, I will.&dquo; Direct and honest answers will perhaps diminish a child’s fears to some extent. 2. Avoid denying the child’s perception or reaction to death. Reactions toward death vary among individuals, perhaps than toward any other phenomenon. Reassure children that children and adults should cry if that is what they feel like doing when feeling hurt by a loss of a significant person. All questions should be treated with equal concern and forthrightness. Avoid giving the impression that an area is &dquo;taboo&dquo; or that the question should not have been asked. 3. As much as feasible, introduce children to concepts of death in czn objective, simple, nonpersonal situation. The parent or teacher of -a child who finds a dead goldfish floating in a tank has several alternatives: 1) disposal of the dead fish, 2) disposal and replacement of the fish without the child’s knowledge of the
considerably more
death, or 3) discussion with the child about the death, disposal, and replacement of the dead fish. The last alternative provides the best experience. The death of a pet in the child’s home is often his first experience with the loss of something meaningful. A rapid replacement of the pet may not only deny the child the opportunity to experience grief, but indicate that persons, like pets, can be easily and quickly replaced. 4. Present children with a discriminating concept of death. Not all deaths are the same, and all are considerably more tragic than what the television screens portray. Such meaningful ideas can be developed early in the child’s life. For example, as young children develop concepts of cleanliness, they learn that soap kills germs. Discussions of sources of foods reveal that some plants and animals are killed for food for other animals or for people. Further, dead plants and animals are changed back into soil which is in turn good food for new plants. The halloween pumpkin can be buried or planted in the garden. Even very young children may grasp concepts concerning the cycle of life. As children grow older, their concept of death can take an additional meaning which requires more cognition and reasoning. They learn that death also occurs among babies and young children and young mothers and fathers, and not just among
Reassure children that children and adults should cry if that is what they feel like doing when fieeling hurt by a loss of a significant
person. and grandfathers and other older persons. Typically, a child associates death with the &dquo;growing old&dquo; process. Later as he matures, such issues and perplexing
grandmothers
problems as abortion, suicide, murder, capital punishment, &dquo;right to die,&dquo;
war,
and euthanasia will have to be reckoned with. 5. Use ceremonial events surrounding death as
therapeutic learning experiences. Traditional ceremonial events provide opportunities for children to ask questions, make comments, 749
Downloaded from cpj.sagepub.com at Karolinska Institutets Universitetsbibliotek on May 30, 2015
out their real feelings. Children have a natural affinity for ceremonials since these are forms of communication which do not depend upon words. To deny a child the chance to participate in important family events is to deny him important opportunities for therapeutic communication, even though it may not be wise to force him to participate. The wise management of grief in children revolves around the encouragement and facilitation of the normal mourning process, and the prevention of delayed and/or dis-
and
act
seem to
Not all deaths
considerably television
are
more
screens
the same, and all are tragic than what the
portray.
torted grief responses. Gorerl has commented that the more group activity of a structured, ritualized, and ceremonial form there is at the time of an emotional crisis, the more the total personality becomes engaged in the healthful processes of acting out the
deep feelings. When these feelings are repressed and through unhealthy detours
are
find such
illness, self-destructive behavior, nate
denied, the
expression physical
as or
Parents and youngsters of course come from diverse ethnic and religious backgrounds, and the counseling physician should have some insight into the various ceremonial expectations and reactions to death and dying. This type of expertise can prove very helpful when counseling the parents of a Jewish or Spanish child, for
example. Conclusion In order to be more humanistic in their approaches to such controversial issues as sex education and death education, physicians and educators should endeavor to develop meaningful values in all areas that determine the quality of life from beginning to end. Physicians, and particularly pediatricians, become significant facilitators in explaining the mysteries of life and death to
parents and their children. Their
expertise is needed. A greater understanding by pediatricians of the spiritual and sociopsychologic principles behind death and dying, and intelligent sympathy and counseling, can be of great benefit and support in times of family crises.
unfortu-
personality changes.
References
When participating in the funeral ceremony is not feasible or practical, the child could later visit the funeral home with a mature and competent adult who would answer his questions. An older child may be introduced to appropriate literature which explains the various aspects of death and dying including funeral ceremonies. Such excellent publications as Grollman’s’ Ex~l~zining Death to Children, Kubler-Ross&dquo; On Death and Dying, and The America Way of Death by il~Iitford~ answer many questions which may be puzzling the adolescent or young adult. Physicians, too, could profit immensely from perusal of the recent literature.
1.
2. 3. 4.
5. 6.
7. 8. 9.
David W., and Daugherty, G. S.: Teaching about death. Today’s Education 62: 46, 1973. Kastenbaum, Robert: The kingdom where nobody dies. Saturday Review December 23, 1972, p. 38. McClure, John W.: Death education. Phi Delta 55: 485, 1974. Kappan Crase, Dixie R., and Crase, Darrell: Live issues surrounding death education. J. School Health 44: 70, 1974. Pitt, Ginny: Psychology of death examined. Associated Press April 12, 1974. Gorer, Geoffrey: Death, Grief, and Mourning. New York, Doubleday, 1965. Grollman, Earl A., Ed.: Explaining Death to Children. Boston, Beacon Press, 1967. Kubler-Ross, E.: On Death and Dying. New York, MacMillan, 1972. Mitford, Jessica: The American Way of Death. New York, Simon and Schuster, 1962.
Berg.
750
Downloaded from cpj.sagepub.com at Karolinska Institutets Universitetsbibliotek on May 30, 2015
C0:~1TINUI1~1G practicing pediatrician
CHALLENGE for the is
meeting
the needs
of parents, many of whom seem less well prepared for parenthood than for almost any other major undertaking. However, many conscientious parents are persistent in
Death and the
their
questions to the pediatrician and take every opportunity to profit from the professional’s knowledge and expertise relative to the child’s physical or emotional health. Sensitive questions often arise about the beginning and the ending of life. Many contemporary parents talk openly with their children about sexuality, childbirth, and the biologic processes attending the beginnings of life, but have difficulty in discussing the end of the life cycle. Perhaps the major reason for this difficulty is that death education is not found in the school curriculum. Another explanation is that today’s families live in a death-denying society. Memorial services take the place of funerals; people pass away; flowers wither or fade. Real experiences with death have been taken out of the home, to be replaced with violent death as portrayed on television. For example, a two-year-old discovered discarded flowers in the trash and asked his mother why they were there. When his mother replied that they were dead, he wanted to know, &dquo;Who shot them?&dquo; The following statements by Berg and Daugherty epitomize this succinctly:
Young Child
Some Practical on
Support
Suggestions
and
Counseling
Dixie R. Crase, Ph.D., Darrell Crase, Ph.D.†
Not too many years ago, dying and death were very much a natural part of the total family life cycle. Families lived together, often with several generations in the same household. The dying process took place within the family circle as did the death itself and the funeral in many cases. Young people °
* Associate Professor of Child Development, Departof Home Economics, Memphis State University. &dag er; Associate Professor of Health and Physical Education, Department of Health, Physical Education, Memphis State University, Memphis, Tenn. 38152. ment
747
Downloaded from cpj.sagepub.com at Karolinska Institutets Universitetsbibliotek on May 30, 2015
thus enabled
view the processes of and bereavement as natural parts of the total life cycle. This is not true today, because these processes are typically removed from the family experience. In many instances, the act of dying has lost its dignity and normalcy and has become institutionalized, dehumanized, and mechanized-and young people have been excluded from the experience altogether. The resulting void of experience must be filled if society is to retain a proper perspective toward the value of life.’ were
to
dying, death, grief,
Many parents want to shield children and young people from a knowledge of or experience with death. Yet, part of the adventure into life is the understanding of death.
Kastenbaum,
thorities
on
one
death and
of the
dying,
current au-
wrote:
’The Kingdom where nobody dies,’ as Edna St. Vincent Millay once described childhood, is the fantasy of grownups. We want our children to be immortal-at least temporarily. We can be more useful to children if we can share with them realities as well as fantasies about death. This means some uncomfortable moments. Part of each child’s adventure into life is his discovery of loss, separation, nonbeing, death. No one can have this adventure for him, nor can death be locked in another room until a child comes of age.’
A child is entitled
to this phase of his education. Death education is preparation for living.3 An adequate understanding of death is inseparably bound up with the nature and purpose of life.
Expression of Concepts Through Play
of Death
Psychologists are suggesting that death actually begins in late infancy. Children between eight and 12 months of age begin to play such games as peek-a-boo (a name derived from Old English words meaning &dquo;alive or dead&dquo;). Very soon after he learns that some things do not return; they may instead be &dquo;all-gone.&dquo; The young child’s awareness
fascination with the toilet may in part be due the concept of &dquo;all-goneness.&dquo; Perhaps the toddler experiments with experiences of to
separation, loss, realize.
and
nonbeing more than
we
Preschool children often play out their developing concepts of life and death. &dquo;He’s dead; call the doctor quick!&dquo; suggests that preschoolers have not grasped the finality of death. Not until children are about nine years of age do they comprehend the universality, irreversibility, and inevitability of death. Their conceptions of death are then to some extent dependent upon their family’s religious beliefs. Chasing games during this age period are interpreted as death being &dquo;it.&dquo; The adolescent often fluctuates between knowing that death is inevitable and final and believing that it is reversible and 4
escapable.4 These comments suggest that death emucation should become a part of the development of individuals, especially when relevant issues arise. Most pediatricians will have the opportunity to counsel with families during a critical disease or a loss of life, and can counsel them regarding the right words, feelings, and explanations so necessary at those times.
Basic Principles in
Counseling
Some physicians seem to have inadequacies fears in the handling of death.’ Regardless of whether the physician, parent, or someone else is instrumental in the counseling of a child on the sensitive issue of death and dying, certain fundamental prinor
worthy of being pursued:e questions about death truthfully, and directly. First, try to discover simply, what the child is asking or is inexactly terested in knowing. When the young child asks, &dquo;What will happen if Mommy dies?&dquo;, he may be wanting to know &dquo;Who will take care of me?&dquo; Responding to such an inquiry by asking, &dquo;What do you think?&dquo; may give the child the opportunity to clarify his specific concerns. Explanations about death and circumstances surrounding family grief should be simple and nonperplexing. For example, explanations such as &dquo;Grandmother has gone on a long trip&dquo; or &dquo;to die is to sleep&dquo; may be confusing for very small ciples
are
1. Answer
children, and will have those who
are
to
older.
748
Downloaded from cpj.sagepub.com at Karolinska Institutets Universitetsbibliotek on May 30, 2015
be clarified for
Questions about death must be answered truthfully, with answers which can form the foundation for later concept development. This may mean acknowledging uncertainty, differences of opinion, or the mystery of death. Explaining what will happen to a child faced with terminal illness, though Many contemporary parents talk openly with their children about sexuality, childbirth9 and the biologic processes attending the beginnings of life, but have difficulty in discussing the end of the life cycle.
exceedingly difficult for both parent and physician, should be done as simply and reassuringly as possible, yet truthfully. The following comments epitomize this notion rather well. Kubler-Ross, one of the foremost pioneers in these studies, was asked by a dying child, &dquo;Am I going to die~&dquo; &dquo;Yes, you are going to die,&dquo; she replied. The young child continued, &dquo;And when that long, black car [hearse] comes to get me and carries me to the cemetery will you sit beside me and ride to the cemetery?&dquo; Kubler-Ross again replied, &dquo;Yes, I will.&dquo; Direct and honest answers will perhaps diminish a child’s fears to some extent. 2. Avoid denying the child’s perception or reaction to death. Reactions toward death vary among individuals, perhaps than toward any other phenomenon. Reassure children that children and adults should cry if that is what they feel like doing when feeling hurt by a loss of a significant person. All questions should be treated with equal concern and forthrightness. Avoid giving the impression that an area is &dquo;taboo&dquo; or that the question should not have been asked. 3. As much as feasible, introduce children to concepts of death in czn objective, simple, nonpersonal situation. The parent or teacher of -a child who finds a dead goldfish floating in a tank has several alternatives: 1) disposal of the dead fish, 2) disposal and replacement of the fish without the child’s knowledge of the
considerably more
death, or 3) discussion with the child about the death, disposal, and replacement of the dead fish. The last alternative provides the best experience. The death of a pet in the child’s home is often his first experience with the loss of something meaningful. A rapid replacement of the pet may not only deny the child the opportunity to experience grief, but indicate that persons, like pets, can be easily and quickly replaced. 4. Present children with a discriminating concept of death. Not all deaths are the same, and all are considerably more tragic than what the television screens portray. Such meaningful ideas can be developed early in the child’s life. For example, as young children develop concepts of cleanliness, they learn that soap kills germs. Discussions of sources of foods reveal that some plants and animals are killed for food for other animals or for people. Further, dead plants and animals are changed back into soil which is in turn good food for new plants. The halloween pumpkin can be buried or planted in the garden. Even very young children may grasp concepts concerning the cycle of life. As children grow older, their concept of death can take an additional meaning which requires more cognition and reasoning. They learn that death also occurs among babies and young children and young mothers and fathers, and not just among
Reassure children that children and adults should cry if that is what they feel like doing when fieeling hurt by a loss of a significant
person. and grandfathers and other older persons. Typically, a child associates death with the &dquo;growing old&dquo; process. Later as he matures, such issues and perplexing
grandmothers
problems as abortion, suicide, murder, capital punishment, &dquo;right to die,&dquo;
war,
and euthanasia will have to be reckoned with. 5. Use ceremonial events surrounding death as
therapeutic learning experiences. Traditional ceremonial events provide opportunities for children to ask questions, make comments, 749
Downloaded from cpj.sagepub.com at Karolinska Institutets Universitetsbibliotek on May 30, 2015
out their real feelings. Children have a natural affinity for ceremonials since these are forms of communication which do not depend upon words. To deny a child the chance to participate in important family events is to deny him important opportunities for therapeutic communication, even though it may not be wise to force him to participate. The wise management of grief in children revolves around the encouragement and facilitation of the normal mourning process, and the prevention of delayed and/or dis-
and
act
seem to
Not all deaths
considerably television
are
more
screens
the same, and all are tragic than what the
portray.
torted grief responses. Gorerl has commented that the more group activity of a structured, ritualized, and ceremonial form there is at the time of an emotional crisis, the more the total personality becomes engaged in the healthful processes of acting out the
deep feelings. When these feelings are repressed and through unhealthy detours
are
find such
illness, self-destructive behavior, nate
denied, the
expression physical
as or
Parents and youngsters of course come from diverse ethnic and religious backgrounds, and the counseling physician should have some insight into the various ceremonial expectations and reactions to death and dying. This type of expertise can prove very helpful when counseling the parents of a Jewish or Spanish child, for
example. Conclusion In order to be more humanistic in their approaches to such controversial issues as sex education and death education, physicians and educators should endeavor to develop meaningful values in all areas that determine the quality of life from beginning to end. Physicians, and particularly pediatricians, become significant facilitators in explaining the mysteries of life and death to
parents and their children. Their
expertise is needed. A greater understanding by pediatricians of the spiritual and sociopsychologic principles behind death and dying, and intelligent sympathy and counseling, can be of great benefit and support in times of family crises.
unfortu-
personality changes.
References
When participating in the funeral ceremony is not feasible or practical, the child could later visit the funeral home with a mature and competent adult who would answer his questions. An older child may be introduced to appropriate literature which explains the various aspects of death and dying including funeral ceremonies. Such excellent publications as Grollman’s’ Ex~l~zining Death to Children, Kubler-Ross&dquo; On Death and Dying, and The America Way of Death by il~Iitford~ answer many questions which may be puzzling the adolescent or young adult. Physicians, too, could profit immensely from perusal of the recent literature.
1.
2. 3. 4.
5. 6.
7. 8. 9.
David W., and Daugherty, G. S.: Teaching about death. Today’s Education 62: 46, 1973. Kastenbaum, Robert: The kingdom where nobody dies. Saturday Review December 23, 1972, p. 38. McClure, John W.: Death education. Phi Delta 55: 485, 1974. Kappan Crase, Dixie R., and Crase, Darrell: Live issues surrounding death education. J. School Health 44: 70, 1974. Pitt, Ginny: Psychology of death examined. Associated Press April 12, 1974. Gorer, Geoffrey: Death, Grief, and Mourning. New York, Doubleday, 1965. Grollman, Earl A., Ed.: Explaining Death to Children. Boston, Beacon Press, 1967. Kubler-Ross, E.: On Death and Dying. New York, MacMillan, 1972. Mitford, Jessica: The American Way of Death. New York, Simon and Schuster, 1962.
Berg.
750
Downloaded from cpj.sagepub.com at Karolinska Institutets Universitetsbibliotek on May 30, 2015
