- Jennifer S. Linebarger, MD*
- Olle Jane Z. Sahler, MD†
- Kelsey A. Egan§
- *Division of Adolescent Medicine, Golisano Children's Hospital, the University of Rochester Medical Center, Rochester, NY
- †Professor of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
- §Undergraduate Student, Cornell University, Ithaca, NY
After completing this article, readers should be able to:
Describe a developmental approach to understanding death.
Know how to counsel a family or child facing death.
Recognize the spectrum of grief reactions, including complicated bereavement.
Understand the importance of communication skills and resources to use when dealing with a family that must cope with death.
The death of a loved one is a time of powerful emotional upheaval. Infants, children, adolescents, parents, and pediatricians all sense that power and respond in different, highly personal ways. Through vignettes and discussion, this article addresses children's cognitive and behavioral approaches to death, the child's understanding of his or her own impending death, and the response of families (including siblings) to the death of a child as well as communication tools to help the pediatrician in each of these areas.
Cognitive and Behavioral Response to Death
A mother brings her 4-year-old son to the office because she is concerned about his lack of appetite over the past few days. During the interview, while you are asking about food, the boy asks if Rover can eat. On further questioning, you learn that Rover, the family dog, died 1 week ago.
A child's understanding of death and expression of grief are influenced by his developmental level, his experiences with death, and the family's cultural and religious beliefs. Chronologic age alone is not a reliable indicator but can serve as a starting point for discussion, particularly in combination with psychologist Jean Piaget's levels of cognitive development (Table 1).
|Age||Developmental Stage (Piaget)||Perception or Concept||Anticipated Response|
|<2 years||Sensorimotor||Sense separation and the emotions of others||Withdrawal Irritability|
|2 to 6 years||Preoperational||Dead=“Not alive” Death as temporary||Wonder about what the dead “do” Magical thinking|
|6 to 10 years||Concrete operational||Morbid interest in death Others die → I die||Exaggerated behavioral reactions to the idea of death and dead things|
|Adolescence||Formal operational||Adult understanding Existential implications||“Why not me?” Death as an adversary|
Children younger than 2 years of age are in the sensorimotor stage, using their senses and developing motor skills to learn about the world. They are able to express feelings through their behavior. Although children in this stage do not understand death, they can …