— Clinicians can help young patients integrate existing belief systems to process grief
By Rebecca Morse, PhD, MA
I once attended a funeral during which the guests were invited to take a flower from atop a young mother’s casket as a memento. A little boy, her son, was being held by his father. He had been remarkably quiet throughout the funeral and interment process up to this point. Then, I began watching him, watch them. He was looking from the line of people to the casket, to his father, to the line of people, to the casket, to his father. He was starting to fidget. And suddenly, amid the silence, he asked his father “Daddy! Why are they taking mommy’s flowers? They are the lastest she’ll ever have?!”
The purpose of this story? To emphasize that this little boy, with only a handful of years on this earth, who couldn’t possibly have a full, contextual understanding of death, on some minute yet significant level got it. His mother would never get more flowers. At least, none she would be able to appreciate.
Last month, I wrote about how medical professionals should always provide honest and fact-based information when talking to pediatric patients about dying. Yet the question remains: What comes after death?
Children may not ask questions indicative of an existential crisis. They often ask very practical questions: What happens after we die? What will happen to me after I die? Is there a heaven? We must educate those who work with and around children: kids live in a world where death exists and we don’t help them if we don’t tell them, help scaffold their understanding, and better their ability to process difficult emotions.
Having established that children understand more than we recognize, how do we, as health professionals, discuss what comes next? First, the pragmatic recommendations: When discussing anything with a child, it’s best to ensure that the parents or legal guardians know what you will be sharing and why. Second, it’s critical to be mindful of culture. Depending on the family’s background there may be constraints or considerations integral to their belief system. And although the goal is transparency and honesty, to establish a trusting relationship with the child, it doesn’t help if the healthcare professionals and guardians are at odds with one another.
It can also be helpful to ask the child what they know already. What have they learned from their family? What does the child think? Children are remarkable observers. They “science” the world around them; correlation does imply causation to them. So, knowing and being able to understand their existing framework or cognitive schema(s) will help guide you in what to say. Even a child as young as 3 or 4 years old can make correlational connections, as did the young child in my story.
In my thanatology courses on children and death, I often require students to watch the movie “Ponette.” It’s a perfect example of what not to do. As each adult and older child gives Ponette different responses after her mother dies, she now must navigate conflicting narratives. And none of it makes sense to Ponette, who is engaging in a very healthy grief response: seeking proximity to her deceased mother and wanting to find ways to communicate with her spirit.
When discussing the afterlife and what comes next with kids, if you know the family’s belief or faith you can work with, not against, what the child has already internalized as their working model for their assumptive world. It’s not our place to undermine the child’s trust in their parents or guardians, or to question what the family has taught the child.
So, what might this look like in a clinical setting?
Step 1: Be honest about what you don’t know first-hand. Unless you are Frankenstein’s monster, it’s safe to assume you haven’t been dead yourself or returned from the grave. It’s okay to tell a child that you don’t know. In terms of sharing what you believe, there may be limitations on what you may or may not share based on professional ethical or legal guidelines, in addition to the need to respect the legal and moral rights of the parents.
Step 2: Ask. This is a good opportunity to ask the child what they believe. A child doesn’t need us to have all the answers. Children need a secure attachment base, and to know they can trust the adults in their world. Regardless of the child’s faith of origin (meaning their caregiver’s or cultural belief system that they are still internalizing), they need consistency in messaging, and their caregivers serve as a primary attachment figure. This can be challenging when the child or family has a different belief system than your own. This is where spiritual cultural humility is imperative; never undermine faith just because you don’t share it (e.g., thanatologists dealing with difference). By finding out what the client feels is salient, we can help them process their emotions around it.
Step 3: Help the child learn to label their emotions. Research has demonstrated that when parents have a more extensive vocabulary for emotion-related words, their children are more advanced in both their social and emotional development. Lev Vygotsky, an early developmentalist, was particularly interested in how we can structure learning in children; he posited that a child’s ability to learn and reach their potential is not limited as much by their own abilities, as it is by the ability of the “teacher” or more expert peer to “scaffold” learning. When children can have their emotion-related expressive language scaffolded (meaning built up or supported by a more experienced person), they show better emotional self-regulation. One final tip: children process through play, so don’t be surprised if they engage in imaginary playacting or games to practice what they are learning and to develop self-regulation. It’s perfectly normal if one moment they are crying or distressed and then minutes later they are laughing and silly. Children may also practice social scripts around loss through make-believe interactions with imaginary friends — this is healthy and adaptive as they are learning to adapt to their new world.
Talking with children about death is one of the most challenging things grown-ups must do. I know many parents who would much rather discuss sex than death and dying. Oftentimes, it may fall on healthcare professionals to provide support. Similar to discussing dying with a child, when discussing what comes after death it’s important to keep in mind the child’s cognitive ability, offer honesty titrated in language they can understand, and remember that grief may manifest itself in different ways such as upset tummies, headaches, irritability, and changes in eating and sleeping patterns.
Moral of the story? The best thing we can do to help children deal with death is to lean into those difficult discussions, work within their existing understanding, and allow them to process at their own pace.
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