Literature review on the best way for a caregiver to communicate parental death to a child 3-12 with openness and honesty.
Author: Susannah Zhang
Date: December 10, 2022
The foundation of this critical analysis is three themes synthesized from over a dozen of peer-reviewed articles. The first theme summarizes that five sub-components of death are required for a mature understanding of death. These sub-components include irreversibility (people do not come back to life), inevitability (all living things will die eventually), universality (death happens to all living things), cessation (all bodily and mental processes will cease), and causality (death is caused by the breakdown of bodily functions) (Hopkins, 2014, p. 83). Parents believe their children are not old enough to understand death (Longbottom & Slaughter, 2018), however, children understand irreversibility as the first concept comprehended as early as ages 3-5 (Hopkins, 2014, & Longbottom & Slaughter, 2018). The last sub-concept children comprehend is causality, primarily between ages 6 – 11 (Colman, et al., 2014, Hopkins, 2014, Longbottom & Slaughter, 2018, & Panagiotaki, et al., 2018). The average age for a child to obtain a mature understanding of death is 6.25 years old (Hunter & Smith, 2008). The pattern that children understand irreversibility first and causality last is consistent across cultural groups (Longbottom & Slaughter, 2018, p. 2).
The second theme explains that children primarily learn about death both through their parents and visual media. How parents discuss death with their children influences their child’s understanding of death and how that child will view death moving forward (Longbottom & Slaughter, 2018). Three explanations were found for parental resistance to talking with their children about death. First, parents themselves are emotionally sensitive to the topic of death (Hendricks, et al., 2014). Second, when a parent has low well-being and is poorly adjusting to life after the death of a partner, they are less likely to openly talk about the deceased parent’s death with their child (Hunter & Smith, 2008). Third, most parents in the Renaud, et al. (2015) study only spoke to their children about death when the child was exposed to death. When children are not taught about death, they will form their own understanding of death using either imagination, information they overhear from adults (Longbottom & Slaughter, 2018), and/or narratives from visual media.
Visual media in North American society has become a channel through which children form their understanding of death (Colman, et al., 2014) and has become equally important as the role of school and family environment (Longbottom & Slaughter, 2018). Children are easily exposed to death through children’s movies (Renaud, et al., 2015), making it impossible for a parent to shield them from death. Children ages 2-5 consume approximately 32 hours of visual media per week (Colman, et al., 2014) and children under age 8 spend an average of three hours per day consuming movies and television (Longbottom & Slaughter, 2018). Colman, et al. (2014) found that the death of the main character was higher in children’s animated films than in adult dramatic films. Children are exposed to unrealistic messages about death through visual media which may impact their understanding of death (Longbottom & Slaughter, 2018).
The third theme revealed what to expect from children’s grief processes and grief reactions. Werner-Lin & Biank (2013) state that “children’s grief shapes the way that information is translated and stored in their brain and influences the interpretation of life events as being stressful” (p.2). There are four tasks of mourning by Worden (1996) that Werner-Lin & Biank (2011) identifies for children: 1) accepting the reality of loss, 2) experiencing the pain of the loss, 3) adjusting to life without the deceased parent, and 4) placing the deceased parent into the context of ongoing life and keeping them in their memory in a way that supports growth (p.277). Children’s grief is ongoing and never ends (Werner-Lin & Biank, 2011 & Revet, et al., 2020). Werner-Lin & Biank (2011) further explains that as children go through life, they return to the four tasks of mourning due to life transitions and a maturing understanding of death. When a child has difficulty understanding death, a parent can expect the child to have grief reactions such as distress, regression, separation anxiety, and/or sleep disorders (Revet, et al., 2020, p. 8). While there were three agreed upon themes in this literature review, there were also three areas of debate.
The three areas of debate regarding children’s understanding of death are the impact of the experience of death on a mature death concept, the compatibility of biological and religious death understandings, and whether cognitive ability and socioeconomic status have an impact. Concerning the first area of debate, Bonoti, et al., (2013) and Hunter & Smith (2008) found that previous death experience produces a realistic and mature death concept. On the other hand, Panagiotaki, et al. (2018) and Hopkins (2014) found opposing results that children’s previous death experience with death did not impact their mature death concept. One explanation for this discrepancy is that different methods were used and the children participating in each study were of varying ages.
The second area of debate was the compatibility of biological and religious understandings of death. Bonoti, et al. (2013) and Harris (2011) concluded that religious understandings of death cause children to abandon and give less validity to biological understandings of death. Longbottom & Slaughter (2018), Panagiotaki, et al. (2018), & Hopkins (2014) agree that religious and biological understandings of death can coexist within a child’s death concept. Having both allows children to make sense of the complexity of death (Panagiotaki, et al., 2018). Hopkins (2014) reported that children with religious parents scored the same on their understanding of death as children with non-religious parents. A possible explanation for this tension is that each researcher may interpret the impact of religion on children’s biological understanding of death differently.
The third area of tension was the impact of cognitive ability and socioeconomic status and a child’s understanding of death. Panagiotaki, et al. (2018) concluded that cognitive ability is not a key factor in how children understand death whereas Hopkins (2014) found that children with lower cognitive ability experienced more difficulty in understanding the death concepts. Both studies used different measures of cognitive ability which is a possible explanation for the difference in results. Hopkins (2014) found that socioeconomic status did not impact children’s understanding of the sub-concepts of death whereas Panagiotaki, et al. (2018) found that higher income resulted in children having a better understanding of irreversibility and cessation. Further studies are needed to determine the impact of socioeconomic status on children’s understanding of death.
This literature review revealed gaps that require further research. There was a lack of research on different cultures’ understandings of death. Children across all cultures experience parental death. Further research within a Canadian context across various cultures is suggested for healthcare social workers in Canada to better guide caregivers from diverse backgrounds in having death conversations with their children. Literature concerning communication about death with children is severely limited (Gaab, et al., 2013) and thus requires further study. A final suggestion is for more research to be conducted on children’s grief processes as there is limited and outdated research.
Evidence-Based Recommendations: Disclosing Death to a Child
Eight evidence-based recommendations were gleaned for talking about death with a child:
1) The best way to communicate death with a child is in an honest, reliable, and informative way that opens communication about death and creates trust with the caregiver (Gaab, et al., 2013, Kurowska-Susdorf, 2015, Lane, et al., 2016, & Longbottom & Slaughter, 2018).
2) Best practice is that caregivers should start talking about death before the child experiences death rather than waiting until a death occurs.
3) Caregivers are warned not to use euphemisms when talking about death because euphemisms confuse children (Lane, et al., 2016). Examples of euphemisms are “passed away” (Colman, et al., 2014), “we lost her” (Longbottom & Slaughter, 2018), “went away”, or “went to sleep” (Kurowska-Susdorf, 2015). Euphemisms avoid the biological facts of death and can be interpreted by children that the dead will come back (Longbottom & Slaughter, 2018).
4) Children need to understand that when someone dies, they will not come back to life on earth, that dead is dead (Kurowska-Susdorf, 2015). Though seemingly harsh, Kurowska-Susdorf (2015) states that telling children the truth is better than the child being confused or uncertain.
5) Caregivers are advised to use children’s movies depicting the death of the main character as an opportunity to talk with their child about death and to clarify inaccurate portrayals of death (Lane, et al., 2016 & Colman, et al., 2014). A suggested movie is Lion King as the main character goes on a grief journey throughout the movie and comes to a healthy acceptance of his father’s death (Lane, et al., 2016 & Colman, et al., 2014).
6) Caregivers are suggested to provide biological education about the life cycle and how the body functions to aid their children’s understanding of death concepts (Lane, et al., 2016).
7) Parents are recommended to include children in death rituals such as funerals so that children can learn grief processes through observation (Kurowska-Susdorf, 2015).
8) A parent who models healthy grief and supports their children’s emotional expression is a protective factor for their children. A widow(er) will face complex emotions that may challenge their capacity to support the needs of their children’s grief, therefore, simultaneous therapeutic work is suggested to support grief of both adults and children (Werner-Lin & Biank, 2013).
These recommendations may seem overwhelming but if parents were to follow only one suggestion it should be to talk honestly and openly about death with their children.
Application to Practice
At some point in the career of a hospital social worker, they are likely to work with a family where a child’s parent has died and may even be asked to assist a caregiver in communicating parental death to a child. Werner-Lin & Biank (2013) suggests that social workers who have the opportunity to work with families before the ill parent dies can build a relationship with the dying parent to support their end-of-life wishes and prepare the children and surviving spouse for life after their death (p. 7). While hospital social workers would rarely be involved in ongoing grief support work, they would benefit from using this literature review as a guide to educate and support caregivers in having death conversations with their children and prepare caregivers for how children may process grief. From the research, it was suggested that a social worker encourage all parents to have general conversations about death with their children as early as age 3.
This paper argues that children between the ages of 3-12 can understand and have conversations about death and that best practice is for caregivers to have open and honest conversations with their children about the death of a parent. Three main themes were discovered including sub-concepts of death, the fact that children learn about death through parents and media, and children’s grief processes and grief reactions. Three main areas of debate were whether previous death experience impacts a child’s mature death concept, whether religious views impeded a child’s biological death understanding, and whether cognitive ability and/or socioeconomic status alters a child’s death understanding. Gaps in the research were identified along with suggestions for further research. Eight recommendations were made to benefit caregivers addressing death with a child and uses for social work practice were identified. Parental death is identified as one of the most stressful experiences a child can have (Melhem, et al., 2011), but the long-term impacts can be reduced with evidence based-recommendations from this paper.
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