PERCEPTIONS OF DEATH
AND DYING IN CHILDREN
Infancy through Adolescence
A simple child
That lightly draws its breath
And feels its life in every limb
What should it know of death!
-Wordsworth
Nurse’s Role
• The nurse is often asked to respond to children’s
questions about death and to advise parents and
teachers on how to discuss this topic with
children.
• It is essential for the nurse to know the cognitive
limitations of children at various stages of growth
and development that may result in
misinterpretation or guilt related to the death of a
loved one.
• Following is a brief summary of 4 basic
concepts of death and the behaviors and
common developmental characteristics
of infants & toddlers, preschoolers,
school age, & adolescents.
4 Concepts about Death
1.
Irreversibility—refers to the permanency of
death. Children may perceive the deceased as
having gone away on a trip, and may get angry
when that person doesn’t return.
Concepts of Death cont’d
2.
Finality (Nonfunctionality)—
The state in which all life functions cease
completely.
• Young children often attribute life to all
objects. This is referred to as “animism”.
• They may fear that the person who died
will not be able to “see” in the coffin once it
is closed, because they cannot
comprehend the “ending of
all life functions” that occurs
with death.
Concepts about Death (cont’d)
3.
Causality—children must be helped to
understand the true causes of death.
• Magical Thinking may cause the child to assume
responsibility for the death of a loved one by
concluding that their bad thoughts or unrelated
actions were the cause of the person’s death,
leading to excessive guilt.
Concepts about Death
cont’d
4. Inevitability (universality)—
Everything that is alive must
eventually die.
• Children may initially think of
themselves and their family
members as immortal. Then,
when someone dies, they fear that
everyone close to them will die.
• Helping children to understand that
each person has his/her own time to
die is important.
Questions the nurse might ask to assess the
child’s understanding of death—
• When someone dies,
can they come back to
life again?
(irreversibility)
• What happens to
people after they have
died? Can they still
see or hear or feel
pain? (finality)
• What causes people to
die? (causality)
• Who dies? Does
everyone eventually
die? (inevitability)
Cognitive Perceptions based on
Developmental Stage
• Infants and Toddlers
• Even infants can respond to maternal depression
when grieving. They cannot cognitively
understand death, but they sense a change in
routine and emotional responses of parents.
Feeding and care-giving patterns should be
maintained.
• Infants and Toddlers (cont’d)
• With the development of “object permanence” that
begins in the 2nd half of the 1st year of life, infants &
toddlers become capable of understanding loss & the
concept of “gone”.
• The game “peek-a-boo” has been suggested to be
one of many games about death. It involves repetitive
separation and reunion with important caregivers and
may represent an attempt to understand and deal with
loss.
• Preschoolers
• Tend to deny death as a normal & final process.
Death is like sleep: you are dead, then you are alive
again. Or it is like taking a journey: you are gone,
then you come back again. The belief in the
reversibility of death is a source of comfort.
Preschoolers (cont’d)
• Because of egocentricity—seeing things only from
their perspective, and
• Magical thinking—creating imaginary cause/effect
relationships that may be unrealistic, they cannot
comprehend the universality and permanence of
death, and may react with intense anger or sense of
guilt because of a misinterpretation of the cause of
death and the inability to “wish” the person back to
life.
• School Age
• 6-9 years: early school-age closely resembles the
preschooler. They do begin to see death as final &
that people they love can die. They may be
interested in the biological aspects of death.
• Website with counsel for teachers and caregivers
• National Center for Grieving Children & Families
School Age (Cont’d)
• 9-12 years: As Concrete Formations develop
further, death becomes personal, irreversible, &
inevitable.
• Some children may experience separation anxiety, be
fearful & reluctant to leave home & parents.
• To protect themselves or hide from fear, school-age
children may create stories or jokes about death.
• Explanations need to be simple, concrete, & honest.
• Adolescence
• Teenagers have completed cognitive development of
concepts of time, space, quantity and causality which
gives them a framework within which the idea of death
can be placed.
• They fluctuate between “knowing” that death is final and
inevitable, and believing that personal mortality is an
unfounded rumor.
• Their defiance of death may explain some of their risktaking behavior— “it can’t happen to me”.
Adolescense (Cont’d)
• Have the most difficulty in coping with death. May
feel alone.
• Concern is for the present much more than for the
past or the future
• It is important to engage the teenage child in
conversation that fosters
an openness to express
feelings of grief and loss.
Nursing Interventions when Dealing with
Children’s Reactions to Death
• Infants and Toddlers
• Help parents deal with their
•
•
•
•
feelings so that they can meet
the emotional needs of their little ones
Encourage parents to stay as close to their children as
possible, yet recognizing the parents’ needs
Maintain normal schedules, routines, rituals as much
as possible
If a parent has died, strive to provide a consistent
caregiver for the child
Promote primary nursing
• Toddler
• Help parents deal with their feelings so that they can
•
•
•
•
meet the emotional needs of their little ones
Help parents to understand behavioral reactions of
their children e.g. regression in development, temper
tantrums, etc.
Encourage parents to stay with the child as much as
possible as there may be great fear of separation
from parents
If a parent has died, strive to provide a consistent
caregiver for the child
Promote primary nursing
• School age
• Help parents deal with their feelings so that they can
meet the emotional needs of their little ones
• Encourage parents to stay as close to their children as
possible, yet recognizing the parents’ needs
• Because of the children’s fears of the unknown,
anticipatory guidance is very important
• Because the developmental task of this age is industry,
interventions of helping children maintain control over
their bodies &  their understanding allow them to
achieve independence, self-worth, & self-esteem & avoid
a sense of inferiority
• School Age (continued)
• Encourage children to talk
about their feelings & provide
aggressive outlets
• Encourage parents to honestly answer
questions about dying rather than avoiding or
fabricating euphemisms
• Encourage parents to share moments of sorrow
with their children
• Provide preparation for post-death services in
response to questions about what happens to
the body
• Adolescence
• Help parents deal with their
feelings, allowing them more
emotional reserve to meet the
needs of their children
• Avoid alliances with either parent or child
• Answer adolescents’ questions honestly, treating
them as mature individuals & respecting their
needs for privacy, solitude, & personal
expressions of emotions
• Help parents understand their child’s reactions to
death/dying, especially that concern for present
crises, may be much greater than for future
ones, including possible death
Bereavement Programs
• Grieving after the death of a child is a long-term
process that cannot be resolved in the traditional
health care system.
• Follow-up phone calls to the family one month after
the loss of a child will help to assess how the family
is progressing through the grieving process.
• Referral to a support group such as The
Compassionate Friends,
(www.compassionatefriends.org) a national
organization for bereaved families, parents, and
siblings may be helpful.
• The goal of such a bereavement program is to help the
family in the process of coping with the devastating impact
of the loss of a child and, hopefully, with grief resolution.
There you have it!
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