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Children Coping With A Parents Terminal Illness

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  • 1. Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) Current Approaches to Helping Children Cope with a Parent’s Terminal Illness Grace H. Christ and Adolph E. Christ CA Cancer J Clin 2006;56;197-212 DOI: 10.3322/canjclin.56.4.197 This information is current as of January 21, 2010 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://caonline.amcancersoc.org/cgi/content/full/56/4/197 To subscribe to the print issue of CA: A Cancer Journal for Clinicians, go to (US individuals only): http://caonline.amcancersoc.org/subscriptions/ CA: A Cancer Journal for Clinicians is published six times per year for the American Cancer Society by Wiley-Blackwell. A bimonthly publication, it has been published continuously since November 1950. CA is owned, published, and trademarked by the American Cancer Society, 250 Williams Street NW, Atlanta GA 30303. (©American Cancer Society, Inc.) All rights reserved. Print ISSN: 0007-9235. Online ISSN: 1542-4863.
  • 2. CA Cancer J Clin 2006;56:197–212 Current Approaches to Helping Children Cope with a Parent’s Terminal Illness1 Grace H. Christ, MSW, DSW; Adolph E. Christ, MD, DMS Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) Dr. G. Christ is Associate Profes- ABSTRACT Much has been learned about childhood bereavement in the last few decades as sor, Columbia University School of studies have increasingly focused on the direct interviewing of children about their recovery from Social Work, New York, NY. the tragic loss of a parent. It has been shown that children do indeed mourn, although differently Dr. A. Christ is Professor Emeritus, Child/Adolescent Psychiatry SUNY from adults. Important moderating and mediating variables have been identified that impact Health Science Center at Brooklyn their recovery from the loss of a parent, which can be the focus of intervention. When death is and Kings County Hospital, Brook- lyn, NY. expected, the terminal phase of an illness has been found to be particularly stressful for children, This article is available online at yet seldom investigated. Similarly, few studies have explored the impact of development on http://CAonline.AmCancerSoc.org children’s experience and expression of grief. We present research findings that clarify phases in children’s experience during the terminal illness, hospital visits, the death, and its immediate aftermath, as well as how the parent is mourned and issues in longer term reconstitution. Variations in children’s responses in these phases are described as they were experienced by 87 children from 3 different developmental groupings: 3 to 5 years, 6 to 8 years, and 9 to 11 years. Recommendations are suggested for parents and professionals about ways to understand and support children during the terminal illness, at the time of death, and during the phase of reconstitution. (CA Cancer J Clin 2006;56:197–212.) © American Cancer Society, Inc., 2006. INTRODUCTION For a child, the death of a parent is a highly stressful event. Research suggests that it places them at risk for adverse psychosocial consequences. However, with adequate family resources, competent substitute care, and emotional support, bereaved children are better able to return to previous levels of functioning.1– 4 When death can be anticipated, as with a terminal illness, physicians and other health care professionals have an opportunity to ameliorate the impact of the loss. The experiences of adolescents who confront parent loss from illness and the ways professionals can support their coping were reviewed in an earlier article.5 Presented here is an update on current approaches to helping children (age 3 to 5, 6 to 8, and 9 to 11) cope with a parent’s terminal cancer illness and death. These approaches are informed by three areas of research: Y Risk and protective factors that mediate the coping of bereaved children. Y Intervention during the terminal illness. Y Developmental grouping of children to enhance specificity and accuracy of findings and interventions. Suggested are ways to better prepare families and health care professionals to facilitate children’s mastery of adaptive tasks during the terminal phase of the parent’s illness, at the death, and during its immediate aftermath. 1 This work was supported in part by grants from the National Institute of Mental Health (NIMH) (MH41967), the American Cancer Society (PRB-24A), the van Ameringen Foundation, the Society of Memorial Sloan-Kettering Cancer Center, and the Project on Death in America of the Open Society Institute. Volume 56 Y Number 4 Y July/August 2006 197
  • 3. Helping Children Cope with a Parent’s Terminal Illness BACKGROUND Recent studies have also identified a broad range of risk and protective factors that con- Early research in childhood bereavement tinue to be explored, refined, and utilized in hypothesized links between unresolved child- developing interventions and service programs. hood grief and subsequent adult psychopathol- Those currently under study are summarized in ogy.6 – 8 While early studies appeared to Table 1. Prospective and retrospective studies establish a link,9,10 later research was able to confirm the critical role of the surviving parent control for independent, moderating, and me- or caregiver in helping children adapt to a diating variables associated with outcomes that Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) parent’s death. The quality of the relationship suggested child bereavement alone was un- with the surviving parent or caregiver and their likely to be related to adult psychopathology.11 competence in parenting bereaved children are Rather, these studies highlighted the impor- the most consistently identified mediating vari- tance of mediating and moderating factors as- ables.3,15–20 Caregiver attributes that contrib- sociated with bereavement, such as the quality ute to children’s adaptation include more active of parental care and the presence of other ad- coping, less depression, more parental warmth, verse social and psychological occurrences pre- and family cohesiveness.4,20 While the connec- ceding and following the bereavement that tion between children’s mourning experience may have more influence on adult outcomes and adaptation level has not been clearly doc- than the fact of the death.12 umented, better psychological outcomes have Studies conducted shortly after parent death, been associated with broader characteristics, in- including interviews with children, have con- cluding openness of general communication firmed that children do indeed experience with the surviving parent and sharing of infor- grief, sadness, and despair following the death mation about the parent’s death.21,22 Parents of a parent. As Dowdney states in her review of often find it difficult to understand and respond child bereavement research, “Inconsistencies in to their children’s unique, developmentally the literature relate to rates of disorder or dis- specific expressions of grief, which may seem turbance rather than to the manner in which vague, intermittent, and at times inappropriate children manifest distress.”8 The highest rates by adult standards. Adults find that children can of psychological symptoms are found in sam- even appear to be unconcerned, callous, or ples that include children referred for bereave- indifferent. ment services or those from less stable backgrounds or under-resourced family envi- Helping Children Cope During the Parent’s ronments.8,13,14 In adequately resourced and Terminal Illness stable family situations, those with clinical level symptoms extending beyond 1 year after the The surviving parent’s management of the death of a parent are about 20%. For example, terminal illness experience and preparation of Lin reported that 40% of bereaved children had their children for the death are viewed in the clinical symptom levels in a sample of children clinical literature as important mediators of whose families were seeking bereavement ser- children’s bereavement, yet there has been little vices and who were subsequently entered into investigation of the children’s coping during a parent-child skills training program.4 By con- this time period. Siegel reports that children trast, the Harvard Bereavement Study reported (age 7 to 17) whose parents were in the termi- only 19% of their publicly recruited sample of nal stages of illness displayed significantly bereaved children had clinical symptom levels higher levels of depression and anxiety than on the same measure at approximately the same community controls.23 At follow up, between time since the parent’s death.13 These studies 7 and 12 months after parental death, differ- do not include longer-term outcomes. One ences between the groups had become nonsig- study reported an elevation of symptoms 2 nificant.3 These findings suggest that when years after the parent’s death, suggesting the parental death follows a lengthy terminal ill- possibility of later consequences.13 ness, child disturbance may precede the death 198 CA A Cancer Journal for Clinicians
  • 4. CA Cancer J Clin 2006;56:197–212 TABLE 1 Risk Factors Impeding and Protective Factors Promoting Reconstitution Risk Factors Impeding Reconstitution Concurrent stressful life events A negative or non-supportive relationship with the surviving caregiver A poor relationship with the parent who died Low self-esteem and an external locus of control Preexisting mental health problems in the adolescent or the surviving parent or caregiver Circumstances of the death, such as violent or traumatic death Protective Factors Promoting Reconstitution Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) Having a relationship with surviving parent or caregiver characterized by open communication, warmth, and positive experiences Surviving parent able to sustain parenting competence Feeling accepted by peers and other adults, such as relatives and teachers Higher socioeconomic status Internal locus of control, religiousness Intellectual and social competence The opportunity to express thoughts and feelings about the deceased parent and have them validated by others itself. Indeed, for children it may be the time of encouraging adaptive denial to permit quality highest distress. Other recent retrospective time together while symptoms are reduced. studies of bereaved children continue to doc- Many parents strive to limit the adverse im- ument misunderstandings and guilt surround- pact of the loss on their children’s future de- ing the parent’s deteriorating condition and velopment and frequently request guidance terminal illness.24,25 These studies also reported from physicians about how best to communi- bereaved children’s memories of anxiety and cate with their children during the parent’s disappointment when visiting and interacting terminal illness.3,24,28,29 Children and adoles- with the ill parent, memories that remained cents report that they value open communica- painful and disturbing during the first years tion with both parents about the illness and after the death. death, and research suggests that it helps them Few interventions have been developed to during their bereavement.21,26 Younger chil- address these stresses and parenting challenges. dren are less likely than adolescents to receive Only one intervention studied focused on information about their parent’s terminal con- helping surviving parents achieve effective dition before the death.22 This is thought to communication with their children about the occur because young children have less access patient’s impending death, including mediating to adult information, their more limited cog- successful visits when the patient was in the nitive abilities make it difficult to explain the hospital.26 Newer medical treatments have ex- situation to them, and adults, often incorrectly, tended the terminal illness period for many believe they are protecting them from the cancer patients so that it may now include emotional pain of loss by not discussing it with periods of disease exacerbation and aggressive them ahead of time. As a consequence, chil- treatment, alternating with periods of reduced dren’s particular questions and needs during symptoms and disease control when life can their parent’s terminal illness are less under- proceed more normally. This gives families stood. much needed hope, but also creates new adap- tive challenges. Determining prognosis, that is, Age-specific Information when death is imminent is increasingly diffi- cult.27 Both parents and physicians must find When death is imminent, physicians and new ways to communicate about the illness, other health professionals can help prepare par- explaining what children see and hear and pre- ents by providing specific, concrete informa- paring them for difficult times, but also reas- tion and practical advice to facilitate coping and suring them of the parent’s well-being when meeting children’s needs at this very stressful their condition is stable or has improved and time in the family’s life. Unfortunately, re- Volume 56 Y Number 4 Y July/August 2006 199
  • 5. Helping Children Cope with a Parent’s Terminal Illness search on developmentally specific responses, portive intervention) conducted with families although requested by parents, has been lim- beginning 3 to 6 months before the patient ited. While clinical case studies have reported died and continuing for 14 months after death different cognitive and emotional responses of from cancer.26 Families with children who had preschoolers, school-age children, and adoles- a serious preexisting emotional problem were cents, no differences in disturbance by age have excluded. This more homogeneous population been established.8,30 A study of bereaved 3- to made it possible to group children with similar 5-year-old children found that, contrary to the cognitive, emotional, and sociocultural devel- opmental attributes.1 As presented below, this Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) guilt generally described in older children’s grief, children this age experienced no feelings grouping clarified clinically important differ- of causal responsibility.31 Rather they are re- ences in their responses to the illness and death ported to show separation anxiety, depen- of a parent. The exclusion of unpredictable dency, nighttime fears, regressive behaviors, deaths also made it possible to understand the irritability, and impatience.32,33 Another age- impact of the highly stressful reactions to the specific study focused on bereaved adolescents. terminal illness and the value of providing in- Adolescents younger than 15 years old at the terventions during this critical stage. time of the parent’s death were found to be A qualitative analysis was used with the in- more vulnerable to depression than those 15 to tervention interviews of 157 children from 88 19 years of age.34,35 Other clinical literature has families. Five different developmental group- attempted to clarify the grief process during ings were identified: 3 to 5 years, 6 to 8 years, adolescence, but the specific effects of parental 9 to 11 years, 12 to 14 years, and 15 to 17 death on the mental health of this age group years.1,26 The categories were formed by have remained largely unexplored. grouping children who evidenced similar de- velopmental attributes. The parent-guidance intervention focused on family communication NEW DIRECTIONS about the illness, parental competence with Three National Institute of Mental Health their bereaved children, and promoting consis- (NIMH)-supported studies addressed child be- tency in management of family decision mak- reavement issues using prospective rather than ing and direction.36 Information was also retrospective designs.2,13,36 Two programs obtained from parent and child assessments be- studied families following the death of a parent fore and after the parent’s death. The findings to provide generalizable information about the describe children’s experiences and related in- response and recovery processes of expected terventions at three different time periods: (1) and unexpected deaths, including those from when the patient was believed to have a life accident, suicide, and homicide. Worden’s expectancy of at least 6 months;38 (2) at the Harvard Child Bereavement Study yielded im- time of the patient’s death; and (3) during the portant insights about the recovery processes immediate bereavement period. reviewed above. Children and adolescents were more symptomatic at the second than DEVELOPMENTAL VARIATIONS IN CHILDREN’S after the first anniversary of the parent’s RESPONSES TO A PARENT’S TERMINAL ILLNESS death.13,37 Sandler provided a carefully con- trolled parent and child skills training interven- Sample tion. Families were recruited from those seeking preventive bereavement services, and The sample in the MSKCC study included these distressed families improved following a both children and adolescents. The findings series of 12 group sessions.2 presented here were drawn from the 87 3- to The Memorial Sloan-Kettering Cancer 11-year-old children whose families partici- Center study (MSKCC) compared 2 interven- pated in the parent-guidance intervention. tions (a parent-guidance and a telephone sup- There were 11 girls and 7 boys in the 3- to 200 CA A Cancer Journal for Clinicians
  • 6. CA Cancer J Clin 2006;56:197–212 5-year-old group; 16 girls and 16 boys in the 6- ited understanding. Nevertheless, it is often to 8-year-old group, and 18 girls and 19 boys in helpful for parents to give children a script, an the 9- to 11-year-old group. explanation of events that they more fully grasp as they mature. A 7-year-old said of her 4-year-old sister, THREE- TO FIVE-YEAR-OLD CHILDREN: “WHERE DID “Before my mother died, my sister wanted to HE GO?” talk about her death, because she thought it was Key Developmental Characteristics like an exciting thing. She thought she would Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) come back. Now she’s mad because she didn’t Y Early preoperational thinking39 makes it dif- come back.” ficult for them to understand the meaning of Another 7-year-old described her 4-year- the illness and the permanence of death. old sister’s reaction: “The night Daddy died, Y They can repeat a memorized script that she and Mummy came to my bed. Mummy explains the situation, but without under- said, ‘Your father died,’ and my sister was standing it. laughing because she thought something excit- Y Communication is mostly through play and ing had happened. She didn’t know what dead fantasy. means. It was very sad; Mummy cried until the Y Limited language skills make it hard for priest came, then my sister cried too.” The caregivers to comprehend young children’s mother added, “She cried because I cried.” behaviors and moods. During a father’s terminal illness, one Y Their world consists almost exclusively of 4-year-old expressed her anxiety about his ob- family centered around the home and their vious frailty by describing her new imaginary relationship to the primary caregiver(s). companions, brothers and sisters who became Y Separation from a primary caregiver is their ill and died and were immediately replaced greatest source of stress. Even very young with new “bigger and stronger brothers” who children can experience night terrors and watched over her and took care of her. This other more obvious distress responses related play lasted several weeks and was gradually to the sudden and frequent removal of a elaborated as her father’s illness progressed. It primary caregiver. seemed to reflect her anxiety about his symp- Y Fortunately, children this age can accept toms, the well parent’s distress, and her belief competent substitute caregivers, especially if and wish that the father would return and be prepared for the possibility of unexpected able to take care of her again. substitutions. It is important with children this age to Y Young children can become distressed by locate a competent substitute caregiver when the primary caregiver’s outbursts of grief, necessary and repetitively reassure children that their inability to mute or filter strong reac- they are loved and will be taken care of. tions, or their emotional withdrawal from illness or exhaustion. Planning Hospital Visits Intervention during the Parent’s Terminal Illness Some parents misunderstand “open com- munication” to mean the full expression of Three- to five-year-old children can observe their intense grief with young children. One the parent’s loss of strength and function, such 3-year-old developed a fear of entering her as the inability to lift them. “Daddy can’t take father’s hospital room because her young par- care of me anymore,” said a 3-year-old who ents tended to cry together when she was there. observed her father’s difficulty with ambula- The mother was referred to a social worker tion. They begin to understand that something who helped her structure the visits, control her is wrong, but cannot comprehend the perma- strong emotions, limit the time of the visits, nence of death. If the parent discusses it with and bring things for the daughter to do with them, they might say the words, but with lim- her father. The child’s fears decreased and the Volume 56 Y Number 4 Y July/August 2006 201
  • 7. Helping Children Cope with a Parent’s Terminal Illness visits were often pleasurable. If the parent is in things in the coffin with the parent (eg, stuffed the hospital for an extended period of time, animals, pillows, pictures of the parent, or toys young children can be relieved to see them, the child especially likes). however briefly. As children this age experience the parent At times, parents resist having their young not returning day after day, they may become child see them in a debilitated state. If the increasingly angry and distraught over time. parent, child, and hospital staff were prepared, Older siblings can become impatient with hav- the visit structured, and the patient’s condition ing to answer their demanding questions. Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) explained by staff, the visit was positive, and One 4-year-old girl became whiny and the patient was not remembered in a negative clingy after her father died. Occasionally, she way.1 Children generally develop positive sat in his chair with many blankets wrapped memories and images of the parent shortly after around her. When she began complaining of the death. At times a parent resists contact stomach aches, her mother took her to the when in a debilitated state because they do not doctor, and she promptly asked him when she want to risk infection by handling a child or could see her father again. Three months later, they have no energy to cope with a child’s she was able to say, “Daddy died.” emotion and developmentally appropriate physical demands. These situations must be ex- How the Parent is Remembered plained to children to counter their feeling that they are being rejected because they are bad. The children’s memories of the deceased The patient’s vulnerability must also be re- parent were generally positive soon after the spected. Alternative modes of communication death, focusing on pleasurable experiences, (eg, telephone, note cards, or gifts) can be caretaking, and protective functions. Many helpful. loved to hear stories about the deceased parent. One 4-year-old enjoyed when her sister made The Death and Its Immediate Aftermath their father’s favorite pancakes using his “se- cret” recipe or when they carefully tended When death occurs, children in this age Daddy’s garden. Another 4-year-old recalled range require concrete descriptions of what that his father had tickled him; another talked happens to people when they die—loss of with pleasure about how his father had tossed functions, permanence of the death, as well as him up in the air. Recapturing such experi- sadness and other emotions people feel after the ences seemed to comfort them. However, after death. When told of the parent’s death, chil- some time, most children this age requested dren this age are often befuddled, wondering that the surviving parent find a replacement. where the parent has gone. Repetitive ques- Young children wanted a whole family, like tioning about where the parent has gone is the other children in their preschools had. characteristic for weeks and months after the One 5-year-old said, “Next time, get two death. Although such questioning helps chil- daddies, so if you lose one again.” dren this age develop a sense of mastery, it can evoke overwhelming emotions in the grieving, The Course of Recovery: Issues in Reconstitution surviving parent. Having children participate in bereavement play groups or talk with another One mother explained that her 4-year-old adult about the parent who died, like aunts or son was not mourning. Rather, he seemed very uncles of the deceased parent, especially telling happy because she was now home much more stories about the parent, can provide opportu- regularly than she had been during his father’s nities to support the child and at the same time terminal illness. The central focus of children relieve the grieving parent. Children this age this age on the primary caregiver meant that often enjoy bereavement groups, relevant art their consistent and predictable presence was therapy, or other expressive sessions after death essential. The primary caregiver often needed has occurred. Many children also want to place to function as a “Rosetta Stone,” helping to 202 CA A Cancer Journal for Clinicians
  • 8. CA Cancer J Clin 2006;56:197–212 interpret the child’s behaviors and affects to elaborate eavesdropping methods, picking up others, as well as to the child. extension phones, and listening through closet walls. However, we observed that if parents spoke candidly and explained major changes SIX- TO EIGHT-YEAR-OLD CHILDREN: “I THINK I directly, children then felt free to ask questions, KILLED HER” and misunderstandings could be clarified. Key Developmental Characteristics In this age range, children’s awareness of their parent’s death can be quite varied. Many spoke openly about being afraid their parent Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) Y Late preoperational thinking39 includes both magical and logical thinking. would die, even when their parents had previ- Y Children understand the parent will not re- ously told clinicians they thought their children turn and death is universal (it could happen “had no idea” about the parent’s diagnosis and to me). did not understand about their imminent Y Children may be highly emotional and have death. Other children, though aware of the difficulty containing emotions. illness, were unaware of the terminal nature of Y They blame themselves when bad things the current episode. A few were unclear about happen. the diagnosis and therefore were confused Y They may make logical errors, misunder- about what was happening to the parent. Most standing cause and effect. had “anticipatory anxiety” rather than antici- Y They can show fear that aggressive thoughts, patory grief as experienced by adolescents and words, or wishes can be harmful. adults. They sensed something “catastrophic” Y “I prayed my mother would be out of pain was going to happen, and they wondered if the night before she died. I think I killed they or their family would survive it. her,” said a 7-year-old girl. An 8-year-old boy whose father was termi- Y They cannot retrace thinking to origins of nally ill said, “I began to think maybe Grandma error to correct erroneous ideas. and Grandpa would die, my mom would also Y Parental support of self-esteem is still die, and maybe the whole world would end, needed, but now they are also aided by and nothing would be there.” praise of teachers. These children tend to be highly emotional Y Although parents are a primary source of and reactive to the many changes taking place self-esteem, they fear rejection by peers. in the family as a consequence of the parent’s Y A 7-year-old girl cried because a classmate illness. Indeed, this seems the most difficult age said, “You can’t go to the father-daughter for parents to manage during the predeath pe- dance because your daddy is dead!” riod, even though existing research has not Y Language skills are more advanced. necessarily identified them to be at higher risk over the long term. They are upset by both Intervention during the Parent’s Terminal Illness parents’ preoccupation with the ill patient’s condition and their difficulty in listening to the Three types of information are helpful to 6- child or playing with them. They react to sep- to 8-year-old children during the parent’s ter- arations and to changes in their own activities. minal illness: (1) simple, concrete, definitional, They react to the parents’ increased tension, disease-related information, such as the name anger, and depression, and to the lack of hap- of the disease, its progress, symptoms, treat- piness, joy, and celebrations in the home. Ex- ments and causes; (2) simple explanation of the planation of what is happening, even if the causal relationship between the patient’s be- child does not ask, is often helpful and can give havior and appearance and the symptoms and permission for the child to ask more questions. treatment of the disease; and (3) when death is Children this age find it difficult to “reverse” imminent, the prognosis. These children may their thinking once they develop an erroneous well overhear conversations that include this idea. Therefore, even when parents explain the information. One 8-year-old boy developed patient’s withdrawal is not from a lack of love Volume 56 Y Number 4 Y July/August 2006 203
  • 9. Helping Children Cope with a Parent’s Terminal Illness and that the illness causes these changes, they the clinician asked how they were feeling about may remain angry and upset for some time and their mother being in the hospital, they re- require much repetition. These children are sponded angrily that she had been there for 62 also “truth tellers” or “whistle blowers” and days. They knew that because they had been will readily express emotions and situations crossing off the days on a calendar they brought their older siblings have learned to hide or with them. Their behavior improved markedly disguise. after the brief visit with their mother. One 7-year-old girl whose father was termi- As with younger children, preparation for Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) nally ill with a brain tumor described the the visit is essential. When the patient’s condi- changes in their family. “Mom and Dad used to tion and physical state, intravenous bottle, etc., go dancing. They don’t do that any more, and can be explained, the interaction with children Mom is angry all the time. Dad won’t let me sit is facilitated. Discussion afterward is easier and on his lap. I don’t think he loves me anymore.” can more readily clarify any misunderstanding. Parents often find it useful to enlist the help If parents cannot cope with visits, they can help of other adults or professionals to listen to their children by telephone communication and ex- children’s distress. The parent’s own emotional change of letters, drawings, and gifts. However, state as the patient’s death approaches or in the seeing and hearing the patient and his or her postdeath period may limit their capacity to caregivers in the hospital not only provide the attend in a helpful way. child with an important confrontation with reality, but also with reassurance that is difficult Planning Hospital Visits to achieve in other ways. Although the 6- to 8-year-olds do not need Saying Good-bye the parent’s constant presence, as do 3- to 5-year-olds, they do need the parent to be as It was unusual for patients to talk with their consistent as possible with them. For example, children this age about their own imminent this includes letting them know about the pos- death. When an ill parent did so, the child sibility of emergency trips to the hospital and often reminisced with pleasure about having preparing them for how the situation will be said final good-byes to the patient. However, as handled and who will take care of them when others have suggested, saying the word good- both parents are absent. If separations are not bye seemed not as important as a final hug, prolonged, and they are aware of the parents’ squeeze of the arm, and repeated affirmation of whereabouts, they can be tolerant of temporary love. caregivers and babysitters. However, if separa- A 6-year-old said, “I wanted to hear those tions are prolonged, they become distressed, magic words, ‘I love you.’” especially if they are not permitted to visit the An 8-year-old remembered his father say- parent in the hospital. In these situations, a ing, “I love you,” to him. planned visit can reduce their anxiety dramat- One 7-year-old remembered how she had ically and lead to improved behavior at home. hugged her mother. Some patients want to protect their children Another 7-year-old was comforted by re- from their altered appearance. However, we membering that, even though her mother found that most children this age spoke only could not talk any more, she had squeezed her briefly after the death about the sick parent’s hand. For months, she put herself to sleep with appearance. They were more likely to feel re- this tactile memory. jected by the parent’s not wanting to have If children did not say good-bye to the pa- them visit. tient directly, they were often comforted by Six- and four-year-old brothers were re- writing their thoughts down and placing them ported to be fighting more than usual even in the coffin. The mother of one 8-year-old though they had a housekeeper during the day boy placed his letter in her husband’s hand in while their mother was in the hospital. When the casket. 204 CA A Cancer Journal for Clinicians
  • 10. CA Cancer J Clin 2006;56:197–212 The Death and Its Immediate Aftermath and strong, much admired hero or heroine. Active, open, and vocal construction of this In contrast to their younger peers, children image seems to comfort them even though this age generally understand the finality of the such openness continues to be difficult for their parent’s death after an illness and are appropri- grieving parent. Like their younger peers, they ately sad and upset when informed. Many par- also request a replacement parent, less ambiv- ents say telling their young children about the alently if the parent who died was the same parent’s death was the most difficult task they gender as the child. They love talking about had ever faced. These children express sadness, Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) and recalling pleasant episodes they had with anger, and dejection connected with thoughts the parent who died, surrounding themselves about the parent, but then often quickly return with their pictures, and incorporating the par- to normative activities. Even when they were ent’s clothing or other objects into their play. well prepared, some expressed surprise and After a long parent illness, children this age acute distress. They have more physical symp- did express some relief that the parent had died toms than older children, as well as fearfulness, and was no longer suffering. They also felt sleeping problems, and separation anxiety. relief that they had survived what they feared Children this age more than any other might would be a catastrophic event. speak openly and explicitly about wanting to One 8-year-old said, “I can talk more about die so they can be with or visit the parent soon my mom now than I could before she died after the death. Generally, these are transient because the worst has happened and it’s over. I thoughts and not accompanied by suicidal in- don’t have to worry that I might make some- tent or plans. If they persist or became rigid and inflexible, a professional evaluation is recom- thing bad happen [by talking about it].” mended. Their mourning is also frequently ex- Course of Recovery: Issues in Reconstitution pressed by joyous memories of the deceased parent, which is disconcerting to surviving As occurred in every age grouping, most of spouses unless they understand that this is an the children returned to their previous levels of adaptive way to retain a connection to the functioning in psychological state, relationships parent who died. The children spoke openly with parent and siblings, academic performance about talking with the parent who died, and for and activities, and relationships with teachers most, these were comforting experiences. and peers by the end of the first year. It is A 7-year-old girl told her father, “I’m going important to note that most of these families to pray for Mommy tonight when I give the had adequate financial resources to afford hir- blessing. Are you going to be sad?” When he ing substitute parenting and, unlike poor or said he would be, she brought a large box of recent immigrant families, had few other family tissues to the table and told him, “You always stresses. feel better after you cry.” Grief with these children is usually sporadic How the Parent is Mourned and brief. Immersion in school and playing with friends are common even immediately Whatever their religion, children this age after the death and should be encouraged. tend to locate the parent who died in a place Schools can be very helpful if teachers are no- (usually heaven) and often with a function. tified. Many children were given permission Most thought the parent watched over them. for short visits to school counselors when they After receiving coins for her lost tooth, one felt sad. 7-year-old girl said, “I know where Mom is— A 7-year-old was overjoyed when one of she’s the tooth fairy!” Her father affirmed that her friends came to the funeral and went to play he thought her mother would love that job. with her. The image retained of the parent is that of Another 6-year-old felt reassured and ac- the loving caregiver, provider of good things, cepted when classmates gave her a large bowl Volume 56 Y Number 4 Y July/August 2006 205
  • 11. Helping Children Cope with a Parent’s Terminal Illness of notes and drawings they made for her after help with the care of the ill parent; however, her father died. they should not be left independently in At home, bedtime is especially hard. Parents charge of a seriously ill parent. were encouraged to spend time each night reading a story and talking about pleasant Intervention during the Parent’s Terminal Illness memories of the parent. Some slept with the parent for weeks or months. Many children this age showed a need for These children reacted more to additional carefully sequenced information about the par- ent’s illness, treatment, and impending death. Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) stress or pressure, some with increasing diffi- culty in separating from their parent when they They were able to integrate relatively concrete and detailed information about the illness with- were going to school, and even more so on out becoming overwhelmed and confused. Mondays after a weekend at home. Parents However, they became frustrated and angry if sometimes included a love note with lunches they were not given enough information. They or gave permission for the child to call home were unable to comprehend the context in the for a quick chat. Limit setting, temper out- absence of more comprehensive detail. bursts, temporary regression like bed wetting, An 11-year-old boy said, “Last year, Dad and clinging were common. Parents appreci- went to the hospital, but they didn’t tell me it ated advice about handling those behaviors, was cancer. I thought it was not cancer, just a understanding them as normal, and gradually tumor. My mom finally put it straight to me, improving behaviors. Difficulty in concentrat- but I had to go up to her and ask. Now that I ing in school and a drop in grades were com- know what’s going on, I understand. Dad used mon, and children needed to be reassured that to be grouchy, and I didn’t understand. I those problems were understandable and tem- thought he was mad about something. Now it porary. For most children, misbehavior took doesn’t seem that he is mad at me.” place at home, not in school. Parents grudg- In contrast to younger children, who could ingly appreciated that as a better alternative. become fixated on particular erroneous ideas, children this age were able to reverse their NINE- TO ELEVEN-YEAR-OLD CHILDREN: THE thinking and correct logical errors. YOUNG SCIENTIST A 9-year-old girl described how she was different from her 6-year-old sister. “She is Key Developmental Features much younger, and she doesn’t take things as well as me, she doesn’t understand.” She ex- Y There is a major change in thinking ability plained that when her parents clarified the fact (concrete operational)—these children can that she was not responsible for her mother’s use logical thinking, understand cause and illness, she believed them, but her sister was not effect, and retrace memories to reverse and so sure. “I know it’s not my fault, and I correct erroneous conclusions. couldn’t have done nothing to prevent it. It Y Unlike early adolescents, they cannot draw wasn’t our fault.” inferences from insufficient information. The importance of incremental information They need detailed, concrete explanations was highlighted by a study of the responses of about the parent’s illness and course of treat- children this age who lost parents in or had ment to understand and feel a sense of con- high exposure to the 9/11 World Trade Center trol. attacks. The bereaved children this age were Y In contrast to younger children, they are the most symptomatic group of children in able to use compartmentalization and dis- citywide school surveys.40 The total unexpect- traction to avoid strong emotion. edness of the event deprived them of their Y They may have outbursts of emotion fol- ability to learn incrementally, and they were lowed by embarrassment and avoidance. overwhelmed with the complexity of the event Y These children benefit from being able to and the enormity of the loss. In contrast, the 206 CA A Cancer Journal for Clinicians
  • 12. CA Cancer J Clin 2006;56:197–212 children this age whose parents died of cancer pearance and ability to function, the reduction and who received continuous small doses of in family activities and trips, and the prospect of information about the progression of the illness a future without the parent’s assistance, sup- were among the best adjusted of the five de- port, and love. They experienced some sepa- velopmentally derived subgroups. ration anxiety when the patient was in the Some children in this age group expressed hospital a long time and the well parent spent a sadness about the parent’s expected death great deal of time there as well. Hospital visits rather than only the anxiety experienced by seemed helpful, especially when they included Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) younger children. They were the first group to contact with medical and nursing staff who consistently anticipate the death and feel sad could explain the care and treatment their par- about the future loss. ent was receiving. They even seemed to benefit After a mother told her 10-year-old boy that from walking around the hospital and becom- his father’s current treatment was ineffective, ing familiar with the patient’s environment. he wanted to look at photographs of his father Learning details and facts about the place, the as he had been before the illness. He said he treatment, and the care helped them compre- thought about his father a lot and worried hend the context and achieve some sense of about him. He also wondered, “Who will play relief and control. However, as with younger basketball with me? Who will fix my bike?” He children, preparing the patient, parent, and staff thought he would want to be with his father for the visit helped to avoid misunderstandings. when he died. Careful preparation by the clinicians in the Many children had difficulty in school during MSKCC study may have prevented the nega- the terminal illness, but some children in this age tive results of hospital visits that have been group were able to improve their performance, reported in retrospective studies.24,25 For ex- sometimes as a gift to the ill parent. It was also not ample, some children were struggling with a unusual for these children to offer to help out drop in grades when their parent was hospital- with taking care of the sick parent. ized, and they feared their sick parent was A 10-year-old boy volunteered to sleep in disappointed in their performance. The parent the den with his father, waking up every 3 or 4 needed to understand that it was normal to hours to give him medication. He said he liked have declines in grades at this time, an expected to help. consequence of the love and worry of their An 11-year-old girl became so expert at help- child, and that it was important to praise their ing to transverse her father from the bed to a efforts during the difficulties of parent illness. wheelchair or stretcher that she instructed the Children also valued the exchange of gifts and ambulance workers how to best do it when they cards. Children this age seemed to find final came to take him to the hospital. Her father was visits meaningful even when little communica- very proud of her special competence. tion was possible. They provided concrete ev- However, parents are cautioned about the idence of the reality that the patient was dying importance of not leaving a child of this age and gave them an opportunity for final inter- placed independently in charge of the care of a action. terminally ill parent. Unfortunately, where fi- nancial resources are inadequate, this does oc- The Death and Its Immediate Aftermath cur. It places a heavy burden on the child with commonly symptomatic outcomes and com- It was viewed as optimal when a child said plicated bereavement if prolonged or when on hearing of the parent’s death, “I was sur- mistakes are made and the parent then dies. prised, but I knew it [the death] was going to happen because my mother kept me in- Planning Hospital Visits formed.” Still, managing intense emotions for children this age was difficult. Some had un- Children this age were more distressed than usually strong reactions, which they later dis- younger children by the parent’s changing ap- avowed. Volume 56 Y Number 4 Y July/August 2006 207
  • 13. Helping Children Cope with a Parent’s Terminal Illness One 11-year-old boy locked himself in his who died as watching them when they were room when his mother came home from the succeeding at school or in sports and imagined hospital because he didn’t want to hear the the parent being pleased with their perfor- news until he was ready. Later, he was embar- mance. Rather than focusing only on the par- rassed about this behavior. ent’s caretaking role, as did their younger peers, Wanting to be alone for a while was not they retained an image of the parent as teacher, unusual. Some children cried or screamed. One coach, advocate, and friend. The mother was boy laughed—an expression of acute anxiety. often remembered as the family organizer, love Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) They needed time to collect themselves. giver, cheerleader, protector, and someone An 11-year-old girl was at school when her with whom they could chat. Requesting a re- mother came to tell her that her father had died placement parent was quite uncommon in after 2 years of struggle with a brain tumor. She comparison to younger children. If it occurred, asked to be able to remain in school with her it seemed related to more practical needs, such friends and to complete a test in her last class. as relieving chores, helping with homework, or She thought her father would have been proud sports. of her good grades during such a difficult time. Like their younger siblings, these youngsters Children this age often avoided their own also like to hear stories about the deceased and others’ strong emotions, especially those parent. The more realistic appraisal of 9- to related to grief. Participation in bereavement 11-year-olds is highlighted by humor, as in the groups or programs could help them to be- following episode: come more open, but often their feelings were An 11-year-old boy, his mother, and older expressed in more indirect ways, as by being siblings were watching the meteor shower messy, stubborn, argumentative, or more with- shortly after the father’s funeral. The 11-year- drawn. They tended to control their grief by old had put two small bottles of his father’s compartmentalizing— escaping by immersion favorite whisky in his casket. Now he pointed in school and extracurricular activities. Diffi- out one star that seemed to careen out of culties with sleeping were ubiquitous; some control; “That’s Dad up there— he found my also developed phobias and fears or a preoccu- bottles of whisky.” pation with ghosts. These children treasured clothing and other Course of Recovery: Issues in Reconstitution items that had belonged to the parent. They provided comfort and opportunities to remi- The course of recovery of 9- to 11-year-old nisce about the parent, especially during the children has much in common with that of first year. They enjoyed looking at pictures of their younger and older peers. Unique to this their parent in healthier and happier days, but age group are emphases on new developmental often in more private and less expressive ways capacities: educational, recreational, and social than did younger children. competencies. The stresses of the terminal ill- ness and the death result for many children in How the Parent is Mourned temporary depression, anhedonia, preoccupa- tion, and reduction in ability to concentrate. Like their younger peers, many children this This sequence of responses can affect all do- age left notes and gifts in the coffin with their mains (educational, recreational, social, and dead parent that reflected activities they en- emotional). An important process of reconsti- gaged in together—a baseball, a letter. Many tution is the gradual regaining of competence listened intently to eulogies and remembered in these areas of great importance to children. them. Some children this age organized their The initial explosive outbursts, withdrawal, own memorial services with their peers, giving and anhedonia are of great concern to the eulogies or contributing to the eulogies of oth- surviving parent. They were helped as single ers.41 They want to be active participants. parents to set limits, support, and encourage These children often thought of the parent these children, sidestepping the provocative 208 CA A Cancer Journal for Clinicians
  • 14. CA Cancer J Clin 2006;56:197–212 nature of the angry meltdowns. However, (2) View communication as a process, not a home and parent remained important to the 9- one-time event. Communicating with children to 11-year-old children. They needed to invest or adolescents about a parent’s terminal condi- in activities outside the home while still retain- tion is best done through careful dosing of ing a close bond. They still valued their parent’s information over time, which builds a pathway love and support. A different dimension of of open communication and trust that children stress and parental trial came from the adoles- will be informed in a timely way about major cents who developmentally needed to separate changes in the parent’s functioning or progno- sis. The level of detail communicated about the Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) from parent and home. The 9- to 11-year-olds, 12- to 14-year-olds, situation is greater with older than younger and 15- to 17-year-olds spent much more time children. Physicians should encourage parents away from home than younger children. The to provide open and hopeful, but not unreal- istic information. Efforts to treat and care for difference, however, is that the 9- to 11-year the ill parent are emphasized, but the child olds often moved to activities outside the must also be assured of their own continued home, while the 2 adolescent groups moved care and love. The resulting dialogue helps away from the close parental contact they pre- children cope with the painful uncertainties viously needed and enjoyed. that both parents and children must endure in this highly stressful period. RECOMMENDATIONS FOR HELPING CHILDREN (3) Children and adolescents generally expe- DURING A PARENT’S ILLNESS ACROSS rience emotional reactions intermittently and DEVELOPMENTAL LEVELS for brief periods of time interspersed with rapid return to normative functioning. Their capac- Some general approaches to helping chil- ity for sustained or intense emotion is limited. dren of all ages during a parent’s terminal illness Sustained, intense grief may reflect symptom- include the following: atic responses to stress rather than health. Their (1) Plan parent visits during a long hospital- intermittent grief, as well as positive memories ization. While some retrospective studies have about the parent, have been found to continue reported lingering distress in children from un- to emerge over the course of their develop- planned visits with the hospitalized par- ment in response to additional stresses or de- ent,24,25,29 others have found that planned velopmental advances.1,43,44 visits are often reassuring. In the MSKCC These and the more specific recommenda- study, at 1-year follow up after the parent’s tions in Tables 2 and 3 are directed to physi- cians and other health care professionals death, most children who had participated in treating life-threatening illnesses in patients the intervention did not report lingering dis- with children; pediatricians and psychiatrists tress about planned visits.1 Others have de- who may treat children with physical or psy- scribed the importance of planning with the chological symptoms of distress; and physicians parent and the patient, if possible, for how the in palliative care programs and in hospices. visit will go, limiting the time of the visit Many physicians will not have direct contact depending on the developmental level of the with family members other than their adult child and the physical and mental state of the patients and their spouses. However, integrated parent, and informing the child about the treat- into competent end-of-life care is the aware- ment and equipment they are seeing.42 While ness that the patient is distressed when the children should be encouraged to visit the par- family is adversely impacted and that the pa- ent at intervals that are not too disruptive to tient wants the health care team to assist with their lives, pushing them to visit if they are their family’s needs. Finally the physician’s sup- strongly opposed is generally not recom- port and appropriate use of direct services to mended, unless it is the only opportunity for a families provided by other members of the final visit. medical team promote effective family- Volume 56 Y Number 4 Y July/August 2006 209
  • 15. Helping Children Cope with a Parent’s Terminal Illness TABLE 2 Recommended Guidelines for Families during a Parent’s Terminal Illness 3- to 5-year-olds 1. Gradually/consistently explain changes due to cancer and treatment without being overly optimistic/pessimistic. Children can learn “script” of events without fully comprehending meaning and importance; at this age, death is not understood as permanent. 2. Separation from primary caregiver is major concern at this age. 3. Establish consistent time when child can ask questions and share feelings, such as bedtime. 4. Provide consistent substitute caregiving when primary caregiver is unavailable. 5. Use play and art to illustrate and concretize complex events that are occurring in family. 6. Having “a good cry together” may be frightening rather than cathartic for young children. Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) 7. Anticipate child’s increased separation anxiety and need for reassurance that they will be cared for. 8. Normalize intermittent, brief intense emotional expression—changing subject and going off to play are important safety valves. 9. Encourage planned, time-limited visits during prolonged parental hospitalizations. Assure child has toys, activities to do with ill parent and that parent’s condition, limited capacity is explained. 10. Offer families consultation with social worker or other psychosocial professional for additional concerns. 6- to 8-year-olds 1. Provide timely information to children about parent’s illness; explain what child is seeing/hearing [eg, explain patient’s withdrawal is caused by illness, not lack of love]. Once children believe their own view of events, it can be difficult to alter. Repetition is required. 2. Children can be overcome by parent’s strong anger or sadness. Controlled emotions are effective for discussing events. 3. Normalize high emotionality at this age. 4. Normalize children’s temporary reductions in school performance when stressed. 5. Engage other family, friends, social workers, or other psychosocial professionals able to listen to emotional concerns if parent has difficulty listening empathically due to own distress. 6. Reassure child of parent’s strength and ability to provide care even when they express strong emotion. 7. Acknowledge situation’s uncertainty and difficulty for everyone. Anticipatory anxiety can occur at this age, and children need support that family will continue. 8. Reassure children that this is not their fault. Children blame themselves when bad things happen. 9. Communicate with the child’s teachers and other significant adults about parent’s illness. 10. Arrange consistent substitute caregiving with people who communicate well with child. 11. Prepare child for medical emergencies that may require parents to leave the house unexpectedly. 12. Children require permission to ask questions and express emotions they fear may upset others. 13. Normalize children’s need to maintain developmentally appropriate activities. 14. Remind parents of their central role in maintaining self-esteem by providing praise. 15. Prepare children to visit with parent in the hospital, explain what they are seeing, and make time for clarification afterward. 16. Consider professional consultation for children this age if severe anxiety, fear, school phobia, preoccupation with self-blame, or persistent depression and low self- esteem occur. 9- to 11-year-olds 1. Give children fairly detailed information when parent’s diagnosis is verified: name of the disease, specifics, symptoms, known causes, treatments, possible side effects—optimistic, hopeful communication, not unrealistic. Account for child’s observations. 2. Assure children the illness is not their fault. 3. Acknowledge the stress of uncertainty for everyone, as well as the strength of family unit. 4. Children this age may have feelings of sadness and loss about possibility of parent’s death. 5. Have child visit during prolonged hospitalizations. Suggest possible discussions; explain parent’s condition and treatment. Children this age can benefit from meeting medical and nursing staff and from exploring the hospital environment. 6. Help child remain involved in after-school activities, sports, and ongoing contact with friends. 7. Support children’s interest in helping with patient’s care, but child should not be independently in charge of the parent’s care. 8. Remind parents that coalitions and special preferences within the family may cause distress. 9. Encourage children’s interest in reading or writing about the disease or treatment and their responses if they want to do this. centered care. Families have been found to consequences and the enhancement of growth- benefit from consultation with a social worker promoting components after the tragic loss of a or psychosocial professional during periods of young parent. high stress and expected loss.45,46 Three research directions for the 21st cen- tury show promise for more specific and less Future Directions confusing and contradictory findings: (1) Studying developmentally homogeneous The last decades of the 20th century con- subgroups of children and the differing effects tributed greatly to knowledge about childhood of different types of deaths; bereavement, but much remains to be under- (2) Conducting longer-term prospective stood about the prevention of later adverse studies that include critical experiences (eg, 210 CA A Cancer Journal for Clinicians
  • 16. CA Cancer J Clin 2006;56:197–212 TABLE 3 Recommended Guidelines for Families Following a Parent’s Death 3- to 5-year-olds 1. Use concrete details to describe the fact that when a person dies, all bodily functions cease and person does not come back. 2. Use play, drawing, and other expressive activities to enhance the child’s understanding. 3. Normalize emotions children and others might feel so they can respond in ways others will understand. 4. Describe what child can expect to happen, what role child can play, roles other people will play, how others will feel and behave, and how child may feel during funerals and memorials. Encourage participation in these rituals. 5. Assign caretaker able to take child out after a brief time if indicated. Such ceremonies are often too long for most preschoolers. 6. Reinforce child’s need to continue positive activities. Downloaded from caonline.amcancersoc.org by on January 21, 2010 (©American Cancer Society, Inc.) 7. Reassure child about their ability and determination to provide continued love and care. 8. Provide transitional objects that seem important to child: deceased’s possessions, clothing, letters, or gifts they may have left for child. 9. Prepare for surge of separation anxiety, sleeping problems, desire to sleep with the surviving parent, clinging behavior, and other temporary regressive behaviors. 10. During first few weeks/months after the death, child may talk frequently about positive memories of parent and ask repeatedly where he/she has gone. 11. Use available groups or bereavement programs for child. Engage others to listen and respond to questions if the parent is overwhelmed with own grief. 6- to 8-year-olds 1. Inform even young children about parent’s worsening condition when death is imminent. 2. Consider final visit with patient—children value final expressions of love. Prepare by describing patient’s condition and suggesting what children can say or do. Just touching the patient can be reassuring and helpful and exchanging gifts meaningful. 3. Provide empathic support for initial responses to parent’s death. Permit return to normative activities. 4. Have children attend traditional rituals and participate whenever possible. 5. Children this age may ask blunt questions around time of the death: “Are you a widow now?” 6. Children’s expressions of grief are often brief and episodic. 7. At this age, increased separation anxiety and sleeping difficulties are likely, often expressed also in stubbornness and problems with behavior. 8. Reassure children of parent’s strength and commitment to continued care and love of the children despite grief of surviving parent. Remember to praise child for their efforts during such a difficult time. 9. Give children objects or possessions of parent who died to provide a sense of connection and solace. 10. Suggest participation in available bereavement programs. 11. Encourage discussion with other adults or professionals when parent is too distressed to listen to child’s often joyous remembrance. 12. Inform the school of the death and explore supportive services available to child should they become upset there. 9- to 11-year-olds 1. Normalize both emotional avoidance at this age and emotional outbursts sometimes followed by embarrassment. 2. Normalize increases in separation anxiety, behavioral and physical symptoms. 3. Invite children to participate in ceremonies, either directly or indirectly through writing about parent or describing their views to other presenters at the rituals. Parents should be open to having their friends attend, as well. 4. Follow child’s lead about returning to school after the death; keep in mind, however, that staying out of school beyond the final ceremonies is usually not helpful. 5. Help child choose appropriate mementos belonging to the patient. 6. Reestablish family routines. 7. Teach and encourage mourning and participation in bereavement programs if available. 8. Inform school of death and explore supportive services available to their child there. terminal stage in predictable deaths, later re- clarify when groups may be unknowingly sponses) that may clarify different outcomes; combined whose findings cancel out clinically and important variables. (3) Combining qualitative and quantitative This century has great promise to provide a analytic approaches provides a way to under- rich harvest of useful approaches to the psycho- stand the realistic complexity of the area and logical support of children exposed to man- populations under study. This may help to made and natural disasters, as well as diseases. REFERENCES parentally bereaved children and adolescents. J adolescents seeking preventive services. J Clin Consult Clin Psychol 2003;71:587–600. Child Adolesc Psychol 2004;33:673–683. 1. Christ GH. Healing Children’s Grief: Surviv- 3. 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