Talking/Being with a three year old about death

[This is a little long for a blog. Perhaps you want to improve on it or comment.] One of my colleagues asked for info regarding response to/from a three year old. Here’s my response:

Hi Bev,

As I mentioned, there is not too much material for helping 3 year olds and death of a loved one, and I would like to receive any better information that you get. I was always amazed at how differences appeared quickly, for we know a 3 year old has a different perception from the usual 4 - 5 year old, and of course quite distinct from a 7 year old. The behavioural/ language development of the 3 year old is rapid, moving into various forms of representation.

Loss to a child is significant - any kind of loss. A child, even a three year old, may act more profoundly to death than an adult. "When children between the ages of two and five are distressed by a loss, they are even more likely to blame themselves for the death because of their imagined 'badness.' As a result, they are particularly vulnerable to failure to mourn adequately." The importance of addressing the death at the child’s level is that if it is not done, then they may have difficulty in forming intimate relationships when they are adults (and may become depressed too). But that’s getting a little deep for what you want, perhaps. Just wanted to indicate the importance of responding to this scenario. Compounding the situation is the view of researchers that children ages 3 - 5 simply do not understand the meaning of death. Add to that the sadness of the grieving of others around the child, the cocktail of suppression and non-understanding can be difficult for the healing of the child.

The meaning of death for the three year old is only understood in degrees. You know that the child cannot conceive of "forever". They think that death is reversible (like the cartoons and TV). Yet they are very sensitive to the emotional climate in their home. Regressive behaviours (clinging, toilet issues, outbursts) can likely occur.

Mary Lou and I have a list which may help a child, although we acknowle that three is a young difficult age.... 1. Tell the truth (the person’s body has stopped working). 2. Let the child share in the grieving. 3. Assure the child of the comforting presence of an adult "You are not alone." 4. Relieve the child of self blame - "This is not your fault" 5. Avoid euphemisms (even for a 3 year old) - lost grandpa; - gone to be with God; asleep... 6. Encourage talking about [grandpa]. 7. Have pictures. 8. Don’t prevent or inhibit expressions of feelings (theirs or yours) Kids can sense that. 9. Don’t mind physical expressions (relate to feelings) pounding the pillow, crying, kicking... 10. Sharing tears is important - crying alone is often not enough. 11. Don’t be alarmed, aggressive behaviours serve a function... help the child substitute other behaviours for aggressive behaviours. 12. Be honest about your own sadness and grief. 13. Accept the child as is... the anger and questioning will pass. 14. Restore or keep a sense of security - asking where grandad is may be a realization that the world is not controlled by the child. 15. Never use a child for one’s own emotional needs (even at that tender age). 16. Help the child get on with a three year old’s interests.

‘Being with’ is as important as ‘speaking with’.

Here is a mnemonic I picked up and adapted from the book A Physician’s Guide to Coping with Death and Dying (Swanson & Cooper, 2005) Remember the C H I L D
* C is for CONSIDER. Treat the child as unique, and not as any child or a little adult. The child has a special relationship to the person who died, especially a grandparent.
*H is for HONESTY. Children can sense when adults are avoiding issues. Even with small children, use the word death, and do not avoid the difficult questions. Where is Grandpa?
*I is for INVOLVE. Although it is late for this situation Bev, suggest they involve the child in the rituals of grief - remembering grandpa at family grace, being thankful for how nice he was, showing pictures.... Do not neglect the child when others are continuing their grief and celebrations.
*L is for LISTEN. Never cut the child off, even when the topic is difficult to discuss (or understand). Adults can help children to identify some of their feelings, including anger and sadness - through drawing for example. Be alert to give assurance that the little one’s thoughts or actions did not cause the sickness or death.
*D is for DO IT OVER AND OVER AGAIN. When parents and adults talk with their children honestly, and as often as necessary, about death and their honest emotions, children learn to deal with their own ‘grief’ - loss. BTW, it also helps the adults in their grieving I think!

(I adapted the following from both Karen Carney, creator of the Grief Education and Support Series, and from the "Crisis, Grief and Healing" website: www.webhealing.com)
Noted child psychologist Alan Wolfelt has said, "Anyone old enough to love is old enough to grieve." Children, then, also need avenues for expression of their fears, sadness, guilt and anger. Their grief response will not "look" the same as an adult. They behave differently in terms of overt reactions. They may appear as though they are disinterested or don't understand the significance of what has happened.

A [child], upon being told that her mother would soon die from metastatic cancer, responded by asking, "When we go to dinner tonight, can I order extra pickles?" She was sending a message that she had "heard enough" for that moment. This child served as the family's "pressure release valve" and would frequently try to lift the mood when it became heavy. To someone unfamiliar with the grief of children, her reaction may have seemed uncaring, or that she did not understand what was being said. Children do grieve in their own way and in their own time.

When a child-centered, age-appropriate explanation and opportunity for commemoration and expression is absent, there may be adverse consequences. A mother was very concerned about her 3 year-old daughter. The child's grandmother died the previous month and the child did not participate in any of the commemorative rituals. The mother explained that she had consulted with the child's pediatrician, who told her that 3 year-olds are too young to attend, because 3 year-olds don't understand death(!) Since Grandmother's death, the little girl had been afraid to go to sleep, and when she did fall asleep she experienced nightmares. During the day she was uncharacteristically anxious and clingy.
Fortunately this child is remarkably resilient, as are most young children. The problem was corrected by offering simple, direct, child-centered, age appropriate explanations. She was told what happens to the body upon death (it COMPLETELY stops working, etc.) and she was also given an explanation of the type of ritual that the family chose based on their religion and culture. She responded by sleeping well, having no more nightmares, and returning to her usual outgoing behavior.

While it is true that 3 year-olds don't understand that death is permanent, final and irreversible, they do understand that something terribly sad has happened. They will miss the presence of people who have died, and they will worry about the sadness they feel around them. Lying to children or hiding the truth increases their anxiety. You can't fool them -- they are remarkably perceptive. When children (of any age) are not given a proper explanation, their incredible imaginations may create images of dead loved ones being buried alive, gasping for air and trying to claw out of the ground. In the case of cremation, they may imagine their loved one being burned alive and suffering horrifically.

Egads Bev, what we put kids through, eh? Or, what they put us through - making us honest!

With warm regards,
David.

Dr. I David Morrison
Cancer Treatment Centre &
Integrated Palliative Care Team
Charlottetown.

Celebration of Life - Cdn Hospice Palliative Care Memorial Service

AGM & Conference
Canadian Hospice Palliative Care Association
Celebration of Life (Canadian Memorial Service) October 26, 2008
Dr David Morrison

Thank you for the opportunity to speak this evening at this important and sensitive celebration. I am humbled and honoured. May our evening reflect hope, joy, celebration and good memories.

If there is one verse of scripture which captures best many of those whom we remember, it is the description of a gracious woman in the Hebrew Bible, in the final chapter of the book of Proverbs (31:25). It says: "Strength and dignity are her clothing and she laughs at the time to come." ‘La force et la dignité est son v tement, et elle se rit du jour venir.’

[After listening to the feminist strength of Sister Elizabeth Davis’ opening speech yesterday, the female gender of the Wisdom literature in Scripture reminds me of one of many end-of-life stories .... Three male professors died in a car crash and before God would let them into heaven (bed shortage?), God gave them a chance to come back to life as anything they wanted.... The first prof said... I want to come back as myself, but 10 times smarter than the Dean. So God made him 10 times smarter. The second prof said ... I want to be better than that Scientist, make me a 100 times smarter. So, God made him 100 times smarter. The last prof decided he would be the best, so he said, "God, make me better than both of them, make me 1,000 times smarter. So God made him a woman.]

Strength, dignity and happiness/laughter -- three great gifts which we honour and celebrate tonight - in the lives of those with whom we have worked, those who have died and whom we honour. We have gained much strength from those who have gifted our lives, whom we celebrate tonight. Those of us here remember the lives of our friends and patients ... and how we heal too. In Andrea’s sensitive words from her poem, The Wave, read this evening ... "Faint hope feathers it’s way into my heart. Can this mean I am healing? .... The message of healing, the promise of a return to joy and aliveness." How all of us need to hear those words.

It is interesting to be back in this historic church. Many years ago I was the Rector of this Parish of St Paul’s. It was large, vibrant ... and with the usual number of seniors and ill in addition to lots of young people. It was a town/gown experiment ... as I retained my post as university professor. In my first year as Rector, there were 17 deaths in this parish. I held many of those as they died. It was 1980. We were just learning the power of morphine - which could keep people relatively pain free while retaining cogency. Yet, those who were dying were kept in the periphery of the hospital. All we could do was bring comfort ... or, as the meaning of that word indicates ... com forté - to be strong with. Many of those were teachers of strength, dignity and happiness, whom I cannot forget. They and many others since then, have showed such strength.

Many of you are nurses, or have nursed friends in palliation and hospice settings. That dynamic nursing symbol, Florence Nightingale, was not an angel, you'll be happy to know. She was a formidably obstinate woman. Her chief aim was to create a climate in medical care that was thoroughly professional. For her, professionalism was whatever served not only the physical health but the dignity of those being cared for. She saw unspeakable conditions in the hospitals of the Crimea. She rebelled not simply against the waste of life. She fought against the offence to life represented by the squalor of contemporary practice. You could say that the modern profession of nursing and palliative care was born out of a passion for human dignity - not just the sense of a practical job to be done. She lived the full conviction that what people require in situations where they are helpless and even dying is respect for their dignity. ... and this no less than medical skill. And our friends who have died needed nothing more nor less than dignity.

This summer a close friend was visiting from the west coast of Canada. A medical doctor, she had spent times volunteering with Mother Teresa ... and we were talking about her diary while there. Florence Nightingale and the more recent Mother Teresa took it for granted that the level of human respect and dignity given to any patient is the same whether they are rich or poor, young or old, likely or unlikely to recover; because they stand on the same ground before their creator. And palliative and hospice care exists in the way it does because this truth has remained constant. Sickness and helplessness are not only matters of bodily incapacity. The "self" is what is ill or hurt or restricted, not simply a set of bodily functions and processes. It is about the service of human dignity. Think of those known to you, your friends, your patients, and perhaps even colleagues ... and as tears come into our hearts, we think of human dignity and love. As we remember our friends and patients, and hold the standard of human dignity, we know that this aspect of life becomes more and more central. We appreciate the work of our Dr Harvey Chochinov and dignity therapy.

It is not simply a western practice. This past June, I had the occasion to again work with leaders of world religions for a week of discussion on human rights and human dignity, at the Institut Ecumenique on the outskirts of Geneva. There were only four of us from Europe or North America. Most religions of the world were represented ... even a Taoist from my favourite country of China, speaking also about Confucianism. Once again, as has always been my experience ... we worked, played and prayed together with full respect. The dignity theme is picked up in our palliative care work, but so also is human rights... and we now have international declarations on the human right to palliative care and pain control. I shall be at the European Palliative Care meetings next June, where this international theme will be reinforced. It emerges in international cancer control. As we remember those with whom we have been so honoured to journey, I never forget that the best of palliative care and pain control is not out of our kindness ... it is their human right based in human dignity.

Specifically in the health care professions, a growing number of people now say that the simply personal and relational skills of healing are squeezed out in training and seriously undervalued in favour of mechanistic skills. We diminish those whom we honour this evening if we participate in the damaging shift away from the fundamental commitment to the service of human dignity.

"Strength and dignity are her clothing...then laughter and happiness....Of course, the laughter of the book of Proverbs goes deeper than a good joke or a witty reply. "She laughs at the time to come": such laughter reflects an attitude of confident hope in the face of adversity and the unpredictable challenges of life. The other reading tonight came from the Beatitudes of the Christian scripture. Usually they are rendered in english as "Blessed are...." Really, a better translation from the original Greek makarios is "Happy" ... for happiness and blessedness are the same thing. Heureux les affligés, car ils seront consolés! Happy are those who are afflicted. They will be comforted. Matthew 5:4 They will be comforted.... comforté.... strong with.... the afflicted will be made strong with those who travel with them.

This evening, we all have some person in mind as we reflect. Perhaps many more than one. This summer it seemed that several died who were both friends and patients. Either patients who became friends, but a few this summer of friends who became patients. You know the pain. There is one woman who represents many ... I performed her wedding right here in this church in 1981. She was also a friend. They lived in central Canada. Her husband was to begin a new medical practice after an army career ... he discovered his cancer...he died of cancer and she was his caregiver. She moved backed home, married again, and continued her career as an outstanding graphic artist. She did work for Dr Rob Rutledge and me, which was shown in many places and other countries. She was doing work for our own cancer centre this past year. Out of the blue, without warning for this young, healthy, talented friend ... an aggressive cancer. She called immediately, of course. Complications arose, and she died within a couple of months. Again, from her and from many others we honour tonight there was strength, dignity and even a laughter of happiness.

Happiness lives for those who cry, those who hurt, those who have searched, and those who tried, for only they can appreciate the importance of people like you, who have touched their lives. The happiest of people don't necessarily have the best of everything; they just make the most of everything that comes along their way. Happiness or blessedness comes through doors you didn't even know you left open. As we remember those for whom we have grieved.... May you have enough happiness to make you sweet, enough trials to make you strong, enough sorrow to keep you human, enough hope to make you happy, and enough money to buy gifts!! Amen.