http://pedslife.com/newindex.php en-us CuteNews http://pedslife.com/newindex.php?subaction=showfull&id=1225630226&archive= by Steven Blanchard, RN

A child's expression of grief is very different than that of an adult. The grieving process may vary widely depending on the emotional maturity of the child and the culture in which the child is raised. It is important for parents, teachers, and professionals to understand the grieving process in children and the methods of support and intervention.

A child may demonstrate a multitude of responses following the loss of a loved one. These responses often dramatically affect the behavior of the grieving child. The child may experience a variety of physical, emotional, and psychological changes. The grieving process in children is not linear. It does not progress neatly from one step to another. Often; the grieving process in children regresses back to prior phases.

The emotional responses often demonstrated by the grieving child include: sadness, anger, irritability, guilt, excessive worry, a feeling of abandonment, and helplessness. These responses may lead to physical symptoms. A grieving child may experience a variety of pains including stomach aches, headaches, chest tightness, shortness of breath, and loss of appetite. The child may also tire easily with a decrease in activity and energy.

Grieving children will display the symptoms of grief in a variety of ways. Some may regress into an earlier developmental stage. For example; a potty trained toddler may suddenly become incontinent again or regress to thumb sucking behavior. A child may withdraw from others or become forgetful. He or she may refuse to go places which serve as reminders of the deceased loved one. Nightmares are common.

How do we help these children work through their grief? Even though there are grief patterns, not all children grieve in the same manner. There is no "right" way to grieve nor is there a wrong way to grieve. The goal should be to allow the child to grieve and offer support. For example; a school age child may not feel it is appropriate to cry in front of classmates. An observant teacher could provide this child an outlet by offering the child an opportunity to cry in a place outside of the classroom.

Because adults so often have difficulties coping with their own mortality they tend to avoid talking about death and too often attempt to protect the child from any discussions of death. Many adults feel a child should be "protected" from seeing the dead loved one or even attending the funeral. If a child is mature enough, that child should be given the option as to whether or not to view the deceased loved one or attend the funeral.

There are many methods available to help a child cope with grief other than just talking. Some children may want to talk. Others may express their grief through a variety of outlets other than verbal communication. Offering the child creative opportunities to express grief may go a long way in helping the child cope with loss. Art, play, dance, music, and activities can sometimes help a child express grief more effectively than conversation.

There are a variety of reliable internet resources available on grief and children. Some of these are listed below:

http://www.goodgriefresources.com
http://www.hospicenet.org/html/children.html
http://www.johgriefsupport.org/
http://www.grievingchildren.org/resources.html

References
Silverman, P.R., & Worden, JW (1992). Children's understanding of funeral ritual, Omega, 25, 319-331.

Doka, K. (1995). Children mourning, mourning children, New York:Routledge.

Bluebond-Langner, M. (1965). The private worlds of dying children. Princeton, NJ: Princeton University Press.

Wolfelt, A.D. (1991). Dispelling Ten Common Myths About Children and Grief Retrieved October 27, 2008 from http://www.goodgriefresources.com/articles/article18.htm]]> 1225630226 Sun, 02 Nov 2008 05:50:26 -0700 http://pedslife.com/newindex.php?subaction=showfull&id=1213449134&archive= by Steven Blanchard, RN

The provision of end of life care for infants and children can present difficult decisions and ethical barriers for health care professionals. Decisions on ending life sustaining treatment must be based on a thorough assessment of the benefits and burdens of continuing aggressive life saving efforts. This assessment must not only include the physical aspects, but should always take into account the emotional and spiritual aspects of witholding life saving efforts. Decisions about what is best for the child should never be made by a single individual.

There will be times of conflict in the decision making process. In the 1970's, Dr. Howard Brody stated that ethics is "the study of the rational process for determining the best course of action in the case of conflicting choices."(1) These conflicting choices may involve members of the health care team, families and friends, spiritual counselors, and administrative personnel. Often, when conflict occurs, it involves more than the physical well being of a child. It usually entails conflicts in the values and perceptions of decision makers.

Making choices on end of life care for children can be an emotional process for the professionals involved. It may even take on a "good vs evil" atmosphere. Before a case escalates to that point, members of the decision making team must understand that the resolution is one of the better good for the child. In considering the better good, it is important to understand that what is in the best interest of any particular child is often ambiguous. In all cases, it can be argued that parents or legal guardians should have the major role in making a choice on end of life care for their child. However; burdens placed upon the family by pursuing aggressive treatment should not be a deciding factor in ending life saving measures.

It is widely accepted that parents and legal guardians have a strong voice in decisions on witholding treatment. Involving children themselves in the process is not so clearly delineated. In ethics, children are considered to have "diminished autonomy" and require the protection of adults.(2) The extent of involvement a child has in the process should be determined more by the child's capacity to understand than the chronological age. Regardless of the extent of involvement a child has in the process, the child should be given as much control over the treatment as possible. Avoid asking children's opinions when a negative answer would be unacceptable. Older children should be given more of a voice in the decision making process and involved more deeply in their treatment regimen.

Summary:
End of life decisions are never easy; especially when children are involved. Parents or the legal guardian should play a major role in the decision making process. Little is known on how parents work through the decision of end of life care for a child. Because of this lack of information, there is no clear-cut method for professionals to assist parents in this difficult process. One thing is clear: The process must involve an interdisciplinary team and the team must present the parents with consistent information. Conflicting messages from the involved professionals may make it impossible for a parent to make a properly informed decision based on the child's best interest.



1. Brody H. Ethical Decisions in Medicine. Boston: Little Brown, 1976, 19.
2. The Hastings Center. Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying. Hastings Center. Briarcliff Manor, 1987.]]> 1213449134 Sat, 14 Jun 2008 07:12:14 -0600