DEVELOPMENTAL PEDIATRICS/BEHAVIORAL HEALTH: Dealing with grief

Pediatricians can be a first-line resource for grieving families, according to David J. Schonfeld, MD. They should be able to support children who are grieving by understanding how children respond to loss and what they, as physicians, can do to support their patients.

In his presentation “Supporting the Grieving Child and Family,” Schonfeld said that, on average, children learn certain concepts about death by 5 to 7 years of age, although younger children who have experienced loss can learn them much younger-even when aged 2 years or younger. Conceptually, children understand:

• Death is irreversible.

• All life functions cease in death.

• Something causes death.

• Everyone will eventually die.

The task is to communicate in ways children can understand. “All gone,” for instance, is the easiest concept and developmentally comes first. “Children have significant capacity to understand things if we know how to explain them in ways that meet where they are developmentally,” Schonfeld explained. He said pediatricians need to recognize that children have this capacity to understand death, and thus should keep some critical elements in mind when dealing with patients and their families:

• Children of all ages grieve.

• Children are reluctant to bring up the subject because they see it causes their loved ones suffering, and they fear increasing (or causing) that.

• Pediatricians need to become comfortable with having the discussion and understand that the child isn’t upset by the conversation, but by the loss.

• Pediatricians need to be advisors, provide information, and direct families to support resources in the community.

Resources to help pediatricians-and the general public-learn and navigate discussions about death are available. Schonfeld cited the free booklet Something Small: A Story About Remembering, available for download at www.achildingrief.com. Pediatricians can download the book or link to it, and can order free hard copies in English and Spanish. The book includes sections on talking to younger children and what they understand at different ages.

“It isn’t that complicated to be supportive, helpful, and empathic,” Schonfeld said. “Grief isn’t something you fix, but is something you can help.”

David J. Schonfeld, MD, FAAP, is chair, Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania.

This presentation is important for 2 reasons: first, parents often look to pediatricians for guidance, and, second, children's physical symptoms can be manifestations of grief. 

Generally I agree with the basic points, although I might quibble with Schonfeld’s comments on development. The work of Brent and Speece emphasize that young children struggle to understand the inevitability of death (eg, that every living thing will someday die and that death can be unpredictable); that death involves cessation, irreversibility; that something causes it (although children might still have magical thinking-“I wished him dead”); and what happens after death. This is a continuing process, and their questions  often will give light to their current struggles.

I would also differ about the age at which children learn these concepts. I think 8 years is a little safer. I certainly would agree on the value of open communication and experience in hastening the process. I totally agree with everything else, and I think it is a sensitive piece and highly important to pediatricians. I would add that often children present their grief in somatic symptoms because that is care eliciting, and the child will often confuse bodily sensations (ie, anxiety is interpreted as "my tummy hurts").

Kenneth J. Doka, PhD, MDiv, is professor of gerontology, College of New Rochelle Graduate School, New York, and senior consultant to the Hospice Foundation of America, Washington, DC.