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A c h i l d 's v i e w o f d e a t h

M. B luebond-LangnerD i d y o u e v e r t h i n k w h e n a h e a r s e g o e s b y t h a ty o u m a y b e t h e n e x t to d i e. T h e y w r a p y o u u p i na b i g w h i t e s h e e t a n d t h e n t h e y b u r y y o u t e nf e e t d e e p .T h e w o r m s c r a w l in a n d t h e w o r m s c r a w l o u t .T h e y c h e w a t y o u r g i z z ar d a n d s p i t i t o u t . A n dt h e n y o u t u r n a v o m i t g r e e n a n d t h e p u s r u s h e so u t l i k e s o u r c r e a m . [ c h i ld r e n 's s t r e e t r h y m e ]

D e a t h i s v e r y m u c h a p a r t o f t h e f an t a s y t h o u g h t s o fc h i l d r e n . I t is p a r t o f t h e g a m e s t h e y p l a y , t h e s t o r i e st h e y h e a r , t h e t e le v i s io n p r o g r a m m e s a n d m o v i e s t h e yw a t c h . Y e t a d u l t s a r e o f t e n m o r e c o m f o r t a b l e t a l k i n gt o c h i l d r e n a b o u t s e x t h a n t h e y a r e a b o u t d e a t h .W h i l e th e q u e s t i o n ' W h e r e d i d I c o m e f r o m ? ' is b e in ga n s w e r e d w i t h i n c r e a s in g c a n d o u r , i t s n a t u r a l o p p o s i t e' W h e r e a m I g o i n g ? ' c o n t i n u e s t o b e a v o i d e d .

T h e r e a r e t i m e s w h e n t h e s u b j e c t o f d e a t h c a n n o tb e ig n o r e d - - w h e n a p e t d i es , w h e n a r e l a ti v e i sd y i n g , a n d m o s t t r a g i c a l l y w h e n a c h i l d i s t e r m i n a l l yi l l . Y e t t h e s e a r e t h e t i m e s w h e n t h e g r e a t e s t e f f o r t sa r e e x p e n d e d i n s h i e l d i n g t h e c h i l d f r o m t h e f a c t s o fd e a t h a n d d y i ng .

T h i s a r t i c l e e x a m i n e s s e v e r a l f a c t o r s t h a t n e e d t ob e t a k e n i n t o a c c o u n t i n a s s e s s i n g c h i l d r e n ' s u n d e r -s t a n d i n g o f d e a t h a n d s u g g e st s g u i d e li n e s f o r t a l k i n gt o w e ll a n d i ll c h il d r e n a b o u t t h e i r o w n d e a t h a n dt h e d e a t h s o f o t h e r s.

Children's views of death: the issue of ag e andstage o f developmentT h e l i t e r a t u r e o n c h i l d r e n ' s v ie w s o f d e a t h i s d o m i n -a t e d b y a d e v e l o p m e n t a l p e r s p e c t i v e . R e s e a r c h e r s ,g o i n g a s f a r b a c k a s th e f i r st h a l f o f t h e 2 0 t h C e n t u r yh a v e t a k e n t h e p o s i t i o n t h a t t h e c h i l d ' s v i e w o f d e a t hr e l a te s t o t h e c h i l d ' s a g e o r s t a g e o f d e v e l o p m e n t .Myra Bluebond-Langner PhD, Professor of Anthropology, RutgersUniversity, Camden, New Jersey 08102, USA.Correspondence and requests for offprints to MB-L.

W h i l e s c h o l a rs h a v e d i f f e r e d a b o u t t h e p a r t i c u l a r a g eo r s t a g e w h e n a p a r t i c u l a r v i e w e m e r g e s o r o n t h ep r e v a l e n c e o f p a r t i c u l a r v i e w s a t a n y o n e a g e o rs t ag e ; t h e r e i s a n a s s u m p t i o n t h a t a t s o m e p o i n t i nt h e m a t u r a t i o n p r o c e s s t h e c h i l d c a st s a s i d e ' c h i ld i s h ,'e x p l a n a t io n s f o r m o r e ' a d u lt , ' c o n c e p t i o n s o f d e a t h( T a b l e 1 ) .

' A d u l t ' i s a s s o c i a t e d w i t h s o m e l a y n o t i o n o fs c i e n ti f i c ( t h a t i s , n o t r e l i g i o u s , a n e m p h a s i s o nb i o l o g i c a l p r o c e s s ) a n d ' c h i l d i s h ' w i t h f a n t a s y . I no t h e r w o r d s , a s c h i l d r e n g r o w u p t h e i r v ie w s o f d e a t hc h a n g e f r o m t h a t o f d e a t h a s a r e v er s i b le p r o c e s s n o tu n l i k e s l ee p i n a n o t h e r p l a c e t o a v i e w o f d e a t h a sa n i r r e v e r s i b l e a n d u n i v e r s a l e v e n t , a c o n s e q u e n c eo f l i v in g , t h e r e s u l t o f p h y s i o l o g i c a l p r o c e s s e s , a g eo r d i s e a s e .

T h i s s c h e m e b r e a k s d o w n w h e n o n e e x a m i n e s t h ef u l l r a n g e o f r e s p o n s e s a d u l t s g i v e t o q u e s t i o n s l i k e ,' W h a t i s d e a t h ? ' o r ' W h a t h a p p e n s w h e n y o u d i e ? 'o r ' A r e y o u g o i n g t o d i e ? ' W h i l e t h e a d u l t s ' i m m e d i a t er e s p o n s e i s to t h e e f f e c t ' O f c o u r s e e v e r y o n e d ie s ; it 'sp a r t o f li f e, ' a n s w e r s o n e w o u l d c o n s i d e r ' m a t u r e ' o r' s c i e n t i f i c ' f u r t h e r s c r u t i n y o f t h e i r r e p l i e s r e v e a l sc o n c e p t s t h a t h a v e p r e v i o u s l y b e e n a t t r i b u t e d t oy o u n g c h i ld r e n . K a s t e n b a u m a n d A i s e n b e r g ~ f o re x a m p l e , r e p o r t t h a t a d u l t d e s c r i p t i o n s o f d e a t h a r er e p l e t e w i t h m a c a b r e i m a g e s , P e r s o n i f i c a ti o n s o fd e a t h a s g e n t l e c o m f o r t e r , g a y d e c e i v e r , g r i m r e a p e r ,w r i n k le d o l d w o m a n a r e n o t u n c o m m o n .

K u b l e r - R o s s ' s ( 1 9 6 9 ) w o r k w i t h t e r m i n a l ly il la d u l t s i s a l s o r e l e v a n t i n t h i s r e s p e c t . S h e d e m o n -s t r a t e s t h a t e v e n a m o n g p a t i e n t s w h o a r e a b l e t oc o n c e i v e o f t h e m s e l v e s a s d y i n g , t h e r e i s a p r e o c c u -p a t i o n w i t h d e a t h a s t h e u l t i m a t e s e p a r a t i o n a n d at e n d e n c y t o p o r t r a y t h e m s e l v e s a s g o i n g o n t oa n o t h e r l if e a f t e r d e a t h . P a t i e n t s p a i n t t h e m s e l v e s ins ce n es w h e r e G o d t a k es t h e m i n t o t h e s p l e n d o u r o fh e a v e n . T h e s e a r e v ie w s w h i c h i n t h e c o n t e x t o f t h ea g e g ra d e d , d e v e l o p m e n t a l m o d e l o f c o n c e p t s o f

C u r r e n t P o e d i a t r i c s (1994) 4, 253 2579 1994 LongmanGroup Ltd 253

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254 CURRENT PAEDIATRICS

Tab le 1 C h i l d r e n ' s v i e w s o f d e a t h : d e v e l o p m e n t a l p e r s p e c t iv e sP e r c ep t i on S t age / age ( s ou r c e )D e a t h a s t e m p o r a r y , n o t f in a l , r e v e r s i b leC o n t i n u o u s w it h l i f e - - d i m i n u t i o n o f a l iv eL i fe g o e s o n u n d e r c h a n g e d c i r c u m s t a n c e sSeparat ion o f c o n c e r nC a u s e d b y e x t e r n a l fo r c e s ( v i o l e n t o r a c c i d e n ta l )D ea t h i s pe r s on i f i ed ( s k e l e t on , t he dea d )

P e r s ona l dea t h c an be av o i de d ( e .g . v i a t r ic k i ng p e r s on i f i c a t i on )C o n c r e t e a n d n o n - s p e c i fi c i d e a s a b o u t l if e a n d d e a t hD ea t h as c es s a t i on o f f unc t i onsD ea t h as f i na l / i r r ev e r s i b l e

D e a t h a s u n i v e r s a l / in e v i t a b l e c a n n o t b e a v o i d e d

S o p h i s t i c a t e d a n d a b s t r a c t p h i lo s o p h i e s a n d t h e o l o g i e s a b o u t t h e n a t u r eo f d e a t h a n d e x i s t e n c e a ft e r d e a t h

P r e o p e r a t i o n a l , y o u n g ( W as s)L e s s t h a n 5 ( N a g y )Less t han 5 ( N agy )P r e o p e r a t i o n a l , y o u n g ( W as s)L e s s t h a n 5 ( N a g y / L o n e t t o )L e ss t h a n 5 ( N a g y / L o n e t t o )P r e o p e r a t i o n a l , y o u n g ( W as s)B e t w e e e n 5 a n d 9 ( N a g y )B e t w e e n 5 a n d 9 ( N a g y )O l d e r c h i ld r e n , b u t u n c o m m o n(Koocher/Kane/Wass)B e t w e e n 6 a n d 8 ( L o n e t to )A d u l t s ( K a s t e n b a u m )B e t w e e n 5 a n d 9 ( N a g y )B e t w e e n 6 a n d 8 ( L o n e t t o )C o n c r e t e O p e r a t i o n a l , M i d d l e c h i l d h o o dand P r ead o l es c en t ( W ass )C o n c r e t e Operat ional , M i d d l e c h i l d h o o dand P r ead o l es c en t ( W ass )C o n c r e t e O p e r a t i o n a l , M i d d l e c h i l d h o o dand P r ead o l es c en t (W as s)B e t w e e n 5 a n d 7 ( S p e e ce )C o n c r e t e O p e r a t i o n a l , M i d d l e c h i l d h o o dand P r ead o l es c en t ( W ass )B e t w e e n 9 a n d 1 0 ( N a g y )F o r m a l c o g n i t i v e o p e r a t i o n s( p r o p o s i t i o n a l a n d h y p o t h e t i c a lded uc t i v e t h i nk i ng ) , ado l es c e nc e (W as s)

death are associated with young children, at veryearly stages of cognitive development.

Are the views of the adult and child fundamentallydifferent? Do they represent differences in concep-tualization? Are these differences the result of aprocess that can be linked to age, or the result ofsome other factors? For example, might the differ-ences be a product of religious education (the childof 6 has little) and/or verbal sophistication.

I would argue that for the adult, the scientific hasnot simply replaced the more fantasy type view;rather they exist simultaneously. As we think aboutdeath, especially our own, more comes into play thancognitive factors. There are emotional factors as wellthat affect our presentation of death. Kastenbaumand Aisenberg 1 studied the views o f college studentsabout death by asking them to write two essays. Inthe first, they were asked to describe how their deathwould take place in the future, when they were intheir sixties. These essays had little in the way ofemotional conflict or drama. They were then askedto describe their death as taking place in the nearfuture. This time their accounts were full of dramaand conflict. The students said that they found thefirst essay the most engrossing which is not whatthe evaluators had predicted. Kastenbaum sees theresponses in the first essay and to the question ofwhich essay they found the most engrossing asindicating the way in which they protect themselvesfrom the inevitability and finality of death by pushingit far into the future. When thinking about death atan earlier age they report less personal involvement,thereby safely distancing themselves from theeventuality.

The importance of considering the emotionalfactors that may play a role in childrens' presentationsof their views of death was u nder scored by Spinatt a 2who found a number of death related anxieties inchildren 6 years old and under and argues that forthose anxieties to be present there must be somenotion of the finality of death. He goes on to pointout that 'To equate the awareness of death with theability to conceptualize it and express the conceptsin an adult man ner denies the possibility of awarenessat a lower level of cognitive development.'

A child can understand mor e than he can articulate.Consider how the toddler can follow multi-stepdirections but cannot necessarily give multistepdirections. Toddlers and young children are exposedto death (e.g. dead animals, sometimes even individ-uals) before they can talk about the experience inany detailed way. We know from their non verbalresponses t hat they re spond to the experience. 1'3

The work of McIntire et aP and Zweig5 amongothers, suggests th at life experiences have more of animpact on concepts of death than age graded ordevelopmental models would predict. In discussingthe results of their study o f the views of death in 598children ages 5-18 years and the studies of othersinterested in the child's views of death, Mc lnti re et alpoint out that children from lower socioeconomicgroups are m ore likely to cite 'violence as the generaland specific cause of death' whereas 'the middle classand older child familiar with all the death delayingtactics of modern medicine sees death as due todisease and old age'.

In comp aring 10 and 11-year old African Americanand American Jewish children Zweig found that the

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A C H I L D ' S V I E W O F D E A T H 2 5 5

Table 2 O t h e r fa c t o r s t h a t h a v e a n i m p a c t o n t h e c h i rd ' sexpressed v i e w o f d e a t hv e r ba l ab i l i t y / s oph i s t i c a t i ond e f e n c e m e c h a n i s m sd e a t h r e l a te d a n x i e t i e sexperiences w i t h i ll nes s and dea t he x p o s u r e t o p o p u l a r c u lt u r e a n d t h e m e d i ae t h n i c a n d c u l t u r a l b a c k g r o u n dr e l i g i ous be l i e f s and p r ac t i c esp e r s o n w i t h w h o m c h i ld i s s p e a k i n gc o n t e x t o f d i s c u s s io n

A f r i c a n A m e r i c a n c h i l d r e n a t t r i b u t e d d e a t h t o a no u t s i d e f o r c e , u s u a l l y v i o l e n t , w h i l e t h e A m e r i c a nJ e w i s h c h i l d r e n s a w d e a t h a s t h e r e s u l t o f a m e d i c a lo r n a t u r a l e v e n t . U n l i k e t h e A m e r i c a n J e w i s h c h i l d r e nt h e A f r i c a n A m e r i c a n c h i l d r e n p e r s o n i f i e d d e a t h a n dt h e y d i d n o t s e e d e a t h a s n e c e s s a r i l y f i n a l.

T h e s e s t u d i e s r a i s e s e r i o u s q u e s t i o n s a b o u t m o d e l so f c h il d r e n 's v i ew s o f d e a t h t h a t w o u l d p r o c e e d f r o ma d e v e l o p m e n t a l p e r s p e c t iv e . T h e y m a k e c l e a r th en e e d f o r a c o n s i d e r a ti o n o f a n u m b e r o f o t h e r f a c t o r s( T a b l e 2 ) n o t l e a s t a m o n g t h e m t h e c h i l d ' s e x p e r i e n c ew i t h i l l n e s s a n d d e a t h .

T e r m i n a l l y i l l c h i l d r e n an d d e a t h : t h e i s s u e o fe x p e r i e n c eT h e n e e d t o l o o k b e y o n d a n a g e g ra d e d , d e v e l o p m e n -t a l m o d e l f o r e x p l a n a t i o n s o f c h i ld r e n ' s v i e w s o fd e a t h w a s d r a m a t i c a l l y d e m o n s t r a t e d f o r m e i n m yo w n r e s e a r c h w i t h t e r m i n a l l y i l l c h i ld r e n , 6 w h e n If o u n d t h a t a g e w a s n o t a t a l l p r e d i c t i v e o f th ec h i l d r e n ' s v i ew o f d e a t h , t h e i r a w a r e n e s s o f t h e i rc o n d i t i o n a n d t h e w a y s in w h i c h t h ey c o m m u n i c a t e dt h a t a w a r e n e s s . F o r e x a m p l e , a 5 - y e a r o l d c o n c e r n e da b o u t s e p a r a t i o n w h o t a l k e d a b o u t w o r m s e a t i n gh i m a n d r e f u s e d t o p l a y w i t h t h e t o y s f r o m d e c e a s e dc h i l d r e n w a s t h e s am e 5 - y e a r o l d w h o k n e w t h a t t h ed r u g s h a d r u n o u t a n d d e m a n d e d t h a t ' ti m e n o t b ew a s t e d '. S o t o o t h e 9 - y e a r o l d w h o d r e w p i c t u r e s o fh e r s e l f o n b l o o d r e d c r o ss e s a n d k n e w t h a t t h em e d i c a t i o n w a s d a m a g i n g h e r li v e r b a d l y , w a s t h es a m e 9 - y e ar o l d w h o n e v e r m e n t i o n e d t h e n a m e s o fd e c e a s e d c h i l d r e n a n d c o u l d n o t b e a r t o h a v e h e rm o t h e r l e a v e h e r f o r a m o m e n t .

I n e a c h o f t h e s e c h i ld r e n w e f i n d v i ew s t h a t a r ee x p e c t e d f o r t h e i r a g e a s w e l l a s o n e s o n e w o u l d n o te x p e c t f r o m c h i l d r e n t h e i r ag e . T o h e a r a 5 - y e a r o l ds p e a k a b o u t w o r m s e a t i n g h im a n d b e i ng c o n c e r n e da b o u t s e p a r a t io n is p r ed i c ta b l e f r o m t h e d e v e l o p m e n -t a l p e r s p e c t i v e , b u t d i s c u s s io n o f d r u g s r u n n i n g o u ti s s o m e t h i n g t h a t a c c o r d i n g t o t h e s e m o d e l s w o u l dn o t o c c u r u n t i l m u c h l a t e r , i n m i d d l e c h i l d h o o d .S i m i la r l y t h a t a 9 - y e a r o l d g i rl c o u l d s t a t e t h a t d r u g sw e r e d a m a g i n g h e r l i v e r i s n o t t e r r i b l y s u r p r i s i n g ,b u t a t a b o o o n n a m e s o f d e ce a s e d c h i l d re n i s m o r ep r o b l e m a t i c i n t e r m s o f th e d e v e l o p m e n t a l m o d e l .

E x a m i n a t i o n o f t h e t e r m i n a l l y ill c h i l d r e n ' s p l a ya n d s t a t e m e n t s r e v e a l e d se v e r a l v i e w s o f d e a t h . T h ev i ew o f d e a t h a s u l t i m a t e s e p a r a t i o n w a s e v i d e n t i n

c h i l d r e n ' s d is p l a y s o f a n g e r . T h e c h i l d r e n s t a t e d a n da d u l t s a g r e e d t h a t t h e s e d i s p l a y s h e l p e d e v e r y o n e t op r e p a r e f o r t h e f i n a l s e p a r a t i o n . F o r e x a m p l e , w h e nI a s k e d J e f f r e y w h y h e y e l l e d a t h is m o t h e r h e r e p l i e d ,' T h e n s h e w o n ' t m i s s m e w h e n I ' m g o n e . ' W h e n Ir e p e a t e d t h i s t o h i s m o t h e r s h e s a i d , ' T h a t ' s r i g h t .J e f f r e y k n o w s t h a t i f h e y e l l s I' l l l e a v e . H e y e l l s s ot h a t I c a n h a v e a n e x c u s e f o r l e a vi n g . H e k n o w sw h e n I c a n ' t t a k e i t i n t h e r e a n y m o r e . 'T h e t e n d e n c y t o v i e w d e a t h a s a s e p a r a t e p e r s o n -a l i t y , o r m o r e c o m m o n l y w i t h t h e s e c h i l d r e n , t oi d e n t i f y d e a t h w i t h t h e d e a d , w a s n o t a b l e i n t w os i g n if i c an t w a y s. F i r s t i t w a s t h r o u g h t h e d e a t h o f ap e e r t h a t t h e c h i l d r e n i n t e r n a l i se d t h e t e r m i n a l n a t u r eo f t h e i r il ln e ss ; w h i c h t h e y w o u l d t h e n p r e s e n t i nc o n v e r s a t i o n t h r o u g h c o m p a r i s o n s o f th e d e c e a s e dw i t h t h e m s e l v e s. A s i n t h is c o n v e r s a t i o n b e t w e e nB e n j a m i n a n d m y s e lf ,B e n j am i n : D r R i c h a r d s t o l d m e t o a s k y o u

w h a t h a p p e n e d t o S y l v i a . ( N o t e : D rR i c h a r d s h a d s a i d n o s u c h t h i n g . )M y r a : W h a t d o y o u t h in k h a p p e n e d t oS y l v i a ?

B e n j a m i n : W e l l s h e d i d n ' t g o t o a n o t h e r h o s p i -t a l . H o m e ?

M y r a : N o . S h e w a s s ic k , s i c k e r t h a n y o u a r en o w a n d s h e d i e d .

B e n j a m i n : S h e h a d n o s e b l e e d s . I h a d n o s e b l e e d s ,b u t m i n e s t o p p e d .

B e n j a m i n w e n t t h r o u g h t h is c o n v e r s a t i o n w i t h e v e r y -o n e h e s aw t h a t d a y . W h e n a s k e d w h y , h e r e s p o n d e d ,' I w a n t t o k n o w w h o m y f r i e n d s a r e .'

S e c o n d , t h e r e w a s a g r e a t r e l u c t a n c e t o m e n t i o nt h e n a m e s o f d e c e a s e d c h il d r e n o r t o p l a y w i t h t h et o y s b o u g h t b y t h e d e c e a s e d ' s p a r e n t s o r p u r c h a s e di n th e c hi ld ' s m e m o r y - - a s i f d e a t h w e r e s o m e h o wc o n t a g i o u s .

T h e s e ' m a g i c a l , f a n t a s y ' v i e w s a r e c o u p l e d w i t hv e r y r e a l s c ie n t if i c vi e w s o f d e a t h . A s T o m ' s c o n v e r -s a t i o n w i t h a n u r s e s o d r a m a t i c a l l y i l l u s t r a t e s :T o m : J e n n i f e r d i e d l a s t n i g h t. 1 h a v e t h e s a m e

t h i n g d o n ' t I ?N u r s e : B u t t h e y a r e g o i n g t o g i v e y o u d i f f e r e n t

m e d i c i n e s .T o m : W h a t h a p p e n s w h e n t h e y r u n o u t ?N u r s e : W e l l m a y b e t h e y w i ll f i n d m o r e b e f o r e

t h e n .D e a t h w o u l d c o m e w h e n t h e d r u g s ' r a n o u t ' .F o l l o w i n g t h i s i n t e r c h a n g e h i s c o n v e r s a t i o n s a b o u td r u g s a n d t h e i r s id e e f f e ct s d i m i n i s h e d . T h e d r u g sw e r e n o t t h e a n s w e r t h a t h e a n d h i s p a r e n t s o n c et h o u g h t t h e m t o b e . A s w i t h o t h e r c h il d r e n a w a r e o ft h e p r o g n o s i s , h e m a d e l i tt l e r e f e r e n c e t o h i s c o n d i t i o no r p r o g r e s s. W h a t w a s t h e r e t o s a y ? T h e r e w e r e o n l yi n d i c a t i o n s o f f u r t h e r d e t e r i o r a t i o n a n d c l o s en e s st o d e a t h .

T o t h e s e c h i l d r e n , c l o s e n e s s t o d e a t h a l s o m e a n tn o f u t u re ; c o n s e q u e n t l y c o n v e r s a ti o n s a b o u t t h e

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256 CURREN T PAEDIATRICSf u t u r e d e c l i n e d n o t i c e a b l y . T h e f u t u r e w a s l i m i t e d t ot h e n e x t h o l i d a y o r o c c a s i o n . T h e c h i l d r e n k n e w t h a th o l i d a y s a n d e v e n t s h a d a n e w s i g n i f ic a n c e f o rp a r e n t s a s w e l l. C h i l d r e n w o u l d o f t e n ta l k a b o u t t h ew a y t h a t h o l i d a y s u s e d t o b e c e l e b r a t e d a n d t h e w a yi n w h i c h i t w a s c e l e b r a t e d n o w t h a t t h e y w e r e i ll. A tt h e s a m e t i m e t h e c h i l d a l s o t r i e d t o r u s h t h e s eh o l i d a y s o r o c c a s i o n s , t o b r i n g t h e m c l o s e r t ot h e p r e s e n t .I n t h e m a i n t h e c h i l d r e n n o l o n g e r s p o k e a b o u tl o n g r a n g e p l a n s a n d g o a l s . T h e y d i d n o t m e n t i o nw h a t t h e y w o u l d b e w h e n t h e y g r e w u p a n d s o m eb e c a m e a n g r y i f o t h e r s d i d . O n e c h i l d w h o w h e n f i rs td i a g n o s e d s a id t h a t h e w a n t e d t o b e a d o c t o r b e c a m ea n g r y w i t h h i s d o c t o r w h e n s h e t r i e d t o g e t h i m t os u b m i t t o a p r o c e d u r e w i t h , 'I t h o u g h t y o u w o u l du n d e r s t a n d S a n d y . Y o u t o l d m e o n c e y o u w a n t e d t ob e a d o c t o r . ' H e s c r e a m e d b a c k a t h e r , T m n o tg o i n g t o b e a n y t h i n g , ' a n d t h e n t h r e w a n e m p t ys y r i n g e a t h e r . S h e sa i d , ' O K S a n d y ' . T h e n u r s es t a n d i n g n e a r b y s a i d , ' W h a t a r e y o u g o i n g t o b e ? ' ' Ag h o s t , ' s a i d S a n d y a n d t u r n e d o v e r .

T h e c h i l d r e n ' s l ac k o f i n te r e s t in f u t u r e p l a n s d o e sn o t r e f le c t a l a c k o f in t e r e s t i n t h e p a s s a g e o f t im e .T h e y w e r e v e r y m u c h c o n c e r n e d a b o u t t h e t im e t h a tt h e y h a d l e f t ; o f t e n p u s h i n g t h e m s e l v e s t o g e t t h i n g sd o n e . S o m e b e c a m e a n g r y w h e n p e o p l e t o o k t o ol o n g t o r e m e m b e r t h i n g s , o r t o a n s w e r q u e s t i o n s , o rt o b r i n g t h i n g s t o t h e m . T h e p a r e n t s a n d s t a f f o f t e nc o m m e n t e d o n s u c h b e h a v i o u r . A s o n e s t a ff m e m b e rc o m m e n t e d ,

' T h e y d e m a n d b e c a u s e t h e y k n o w t i m e is s h or t .I t ' s a s i f t h e y k n o w t h a t i f t h e y w a i t t o o l o n g ,t h e y m i g h t b e d e a d b y t h e n . T h e y ' r e n o t j u s tb e i n g d i f f i c u l t , M a r y i n c l u d e d . T h a t c h i l d k n o w ss o m e t h i n g . ' *

S o m e c h i l d r e n v e r b a l i z e d t h e i r f e a r o f w a s t in g t i m ed i r e c t l y w i t h p h r a s e s l i k e , ' D o n ' t w a s t e ti m e , o r ' W ec a n ' t w a s t e t i m e '. T h e s t a f f o f t e n n o t e d t h e a c t i v i t ya n d u r g e n c y t h a t f o l l o w e d o n t h e d e a t h o f a p e e r.

T i m e t a k e s o n m e a n i n g n o t u s u a l l y f o u n d i n y o u n gc h i l d r e n . T h e s e c h i l d r e n a r e h a v i n g t h e i r t i m e c u ts h o r t a n d t h e y k n o w i t. D e a t h a n d d i s e a s e a r ec o n s t a n t s i n t h e i r li v es . I m a g e s o f d e a t h a n d d i s ea s ef i l l d i s e a s e - r e l a t e d a s w e l l a s n o n - d i s e a s e - r e l a t e d p l a ya n d c o n v e r s a t i o n s .

C h i l d r e n ' s d e c i s i o n s t o d i s p l a y o n e t y p e o f b e h a v -i o u r o v e r a n o t h e r t o p r e s e n t a p a r t i c u l a r v i e w o fd e a t h , r e f l e c t s n o t o n l y t h e i r e x p e r i e n c e s , b u t a l s ot h e ir u n d e r s t a n d i n g o f t h e c i r c u m s t an c e s o f th ei n t e r a c t i o n a n d t h e i r c o n c e r n s a t t h e ti m e . I n t e r a c t i o no f t e n t a k e s p l a c e in t h e c o n t e x t o f m u t u a l p r e t e n c e ;e a c h k n o w s t h e p r o g n o s i s , b u t d o e s n o t r e v e a l t h a tk n o w l e d g e t o t h e o t h e r. A m o n g t h e m a n y r u l es*Mary was a demanding child who nev er said anything directlyabout her prognosis. W hen she died a list of all the children whohad die d and und er wh at circumstances was foun d in a bureaudrawer along with a list of whom who she wanted o receiveparticu-lar belongings.

w h i c h m u s t b e f o l l o w e d i f m u t u a l p r e t e n c e i s t o b em a i n t a i n e d a r e : a v o i d d a n g e r o u s t o p i c s , f o c u s o ns a f e t o p i c s , h e l p i n d i v i d u a l s t o t a k e l e a v e i f i t a p p e a r st h e y w i l l b r e a k d o w n a n d s h a t t e r t h e p r e t e n c e .B e h a v i o u r s s u c h a s a v o i d i n g d i s c u s s io n o f t h e f u t u r ea n d o n e ' s c o n d i t i o n a n d d i s p l a y i n g a n g e r s o t h a tp e o p l e a b o u t t o b r e a k d o w n w i ll h a v e a w a y t o le a v er e f l e ct a d h e r e n c e t o t h e s e r ul e s. C h i l d r e n c o o p e r a t ew i t h t h e p r e t e n c e l e s t t h e y b e l e f t a l o n e , a b a n d o n e d ,a ' f a t e w o r s e t h a n d e a t h ' .

O t h e r c o n c e r n s t h a t m o t i v a t e t h e c h i l d r e n ' s b e h a v -i o u r r e v o l v e a r o u n d t h e p h y s i c a l a s p e c ts o f d y i n ga n d s e p a r a t i o n . W h e n c h i l d r e n f i r s t l e a r n t h e p r o g -n o s i s t h e y a r e m o s t c o n c e r n e d w i t h t h e p h y s i c a la s p e c t s o f d y i n g , e s p e c i al l y m u t i l a t i o n , p a i n a n dd i r e c t c a u s e . T h i s i s e v i d e n t i n c o n v e r s a t i o n s a f t e ra n o t h e r c h i l d h a s d i e d . A s t i m e p a s s e s a n d t h e yi n t e r n a l i s e t h e p r o g n o s i s t h e i r c o n c e r n s s h i f t a n dt h e i r b e h a v i o u r c h a n ge s . T h e y a r e n o w m o r e c a r e f u lt o m a i n t a i n m u t u a l p r e t e n c e w i t h t h o s e w h o m t h e yp e r c e i v e a s d e s i ri n g i t a n d t o p r e p a r e f o r t h e f i n als e p a r a t i o n b y d i s t a n c i n g t h e m s e l v e s f r o m o t h e r s . A tt h i s t i m e i t i s n o t u n u s u a l t o s e e c h i l d r e n w i t h d r a wt h r o u g h d i s p l ay s o f a n g e r , r e f u s a l t o t a l k w i t hp a r t i c u l a r i n d i v i d u a l s , e n g a g e m e n t in b a n a l c h i t c h a t .T a l k i n g t o c h i ld r e n a b o u t d e a t hI f n o t h i n g e ls e t h e r e s e a r c h o n t e r m i n a l l y i ll c h i ld r e nu n d e r s c o r e s t h e n e e d t o l o o k b e y o n d a g e a n d v e r b a lp r e s e n t a t i o n s f o r i n d i c a t i o n o f t h e c h i ld ' s c o n c e p t i o no f d e a th . A s s e s s m e n t o f c h i l d r e n ' s u n d e r s t a n d i n g s o fd e a t h m u s t p r o c e e d w i t h a n a w a r e n e s s t h a t t h e so c i a l,c u l t u r a l a n d p s y c h l o g i c a l f a c t o r s a r e i n o p e r a t i o nw h e n e v e r t h e i ss u e o f d e a t h i s b e f o r e t h e m . I n g e n e r a lw e w o u l d d o b e t t e r n o t t o l o o k a t t h e c o n c e p t o fd e a t h a s f i x e d , b u t r a t h e r a s f l u i d , i n p r o c e s s , a n d a ss u c h s u b j e c t t o c h a n g e . F r o m t h i s p e r s p e c t iv e s ev e r a ls p e ci fi c s u g g e s t io n s f o r t a l k i n g t o c h i l d r e n a b o u td e a t h e m e r g e .T a k e y o u r c u e s f r o m t h e c h i ldT h e i s s u e i s n o t ' t o t e l l o r n o t t o t e l l ' , b u t r a t h e rw h a t to t e l l w h e n t o t e l l a n d w ho s h o u l d d o t h et e ll in g . T h e c h i l d r e n s h a r e d i f f e r e n t k in d s o f i n f o r -m a t i o n w i t h d i f f e r e n t p e o p l e a t d i f f e r e n t t im e s . F o re x a m p l e , w h a t t h e y s a y t o t h e m i n i s t e r a b o u t d e a t h ,i s d i f f e re n t f r o m w h a t t h e y w a n t t o t a l k a b o u t w i t ht h e p h y s i c i a n o r t h e i r p a r e n t s . D i s c u s s io n s a b o u td e a t h o r e x p e r i m e n t a l p r o t o c o l s m a y p r o c e e d r a t h e rd i f f e re n t l y w h e n t h e c h i l d f e el s th e p a r e n t n o l o n g e rw i s h e s t o p u r s u e f u r t h e r t r e a t m e n t , t h a n w h e n t h ec h i l d f e e l s t h e p a r e n t d o e s .A n s w e r w h a t t h e c h i l d w a n t s to k n o wC h i l d r e n w a n t t o k n o w d i f f e r e n t t h i n g s a t d i ff e r e n tt i m e s . I t i s a l o n g t i m e b e f o r e t h e y s e e t h e i r i ll n e s s a sh a v i n g a t e r m i n a l p r o g n o s i s , l e t a l o n e t h e m s e l v e s a ste rm ina l l y i l l. 6 '8 '9 To th i s e nd i t i s he lp fu l to e l i c i t

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A C H I L D ' S V I E W O F D E A T H 2 5 7a s m u c h a s p o ss i b le f r o m t h e c h i l d b e f o r e y o u e n t e ri n t o d i a l o g u e a b o u t t h e p a r t i c u l a r p o i n t i n q u e s t i o n .F o r e x a m p l e e m b e d d e d i n a q u e s ti o n , ' H o w d o e s t h ec h e m o t h e r a p y w o r k ? ' m a y b e a d e s i re to k n o w h o wt h e d r u g a t t a c k s v a r i o u s c e l l s , w h a t t h e s i d e e f f e c t sw i l l b e a s w e l l a s t h e e f f i ca c y o f t h e t r e a t m e n t .

C h i l d r e n w a n t t o k n o w a b o u t t h e i r c o n d i t i o n a n dw i l l t r y t o f i g u r e o u t w h a t i s g o i n g o n r e g a r d l e s s o fw h e t h e r o r n o t t h e y a r e t o l d . M i s i n f o r m a t i o n i sa l w a y s a r o u n d . W r o n g c o n c l u s i o n s a r e a l l t o o e a s yt o d r a w . S i l e n c e t e a c h e s t h a t d e a t h i s t a b o o , d a n g e r -o u s , t o o d i f f i c u lt e v e n f o r a d u l t s t o h a n d l e .

Use terminology and approaches that the child canunderstandD i a g r a m s a n d p i c t u r e s a r e o f t e n h e l p f u l. O n e c a nc h e c k t h e c h i l d ' s c o m p r e h e n s i o n b y a s k i n g t h e c h i l dt o e x p l ai n t o y o u w h a t y o u h a v e j u s t s a i d t h r o u g hs t a t e m e n t s l ik e , ' N o w i f y o u w e r e th e d o c t o r h o ww o u l d y o u e x p l a i n t h i s ? '

Once is not enoughT h e c h i l d ' s d e s i r e t o t a l k a b o u t d e a t h , w h e t h e r w e l lo r i l l , d o e s n o t n e c e s s a r i l y g o a w a y a f t e r o n ed i s c u s s i o n . T h e r e w i l l b e d i f f e r e n t q u e s t i o n s a n dc o n c e r n s i n t h e f a c e o f d i f f e r e n t e x p e r i en c e s . A sv a r i o u s e x p e r i e n c e s a r e p r o c e s s e d t h e i s s ue s t h a t t h e yr a i se n e e d t o b e a d d r e s s e d .

Be honestD o n o t s a y t o a c h i l d w h a t y o u d o n o t b e l ie v e . T h i sd o e s n o t m e a n t h a t y o u c a n n o t r e a s su r e t h e c h il dt h a t h e o r s h e i s l o v e d , w i l l b e c a r e d f o r , n o ta b a n d o n e d .

A l l c h i l d r e n w i l l a t s o m e p o i n t f a c e l o s s a n d w i l lg r i ev e . W e d o n o t h a v e t o , n o r s h o u l d w e e v e n t r y

t o f i x a c h i l d ' s g r i e f . I t i s t h e c h i l d ' s a l o n e , h e o r s h eo w n s i t a n d m u s t w o r k t h r o u g h i t. B u t c h i l d re n n e e dn o t a n d s h o u l d n o t d o i t a l o n e . L e t u s o f f e r c h i l d r e no u r s u p p o r t a n d e n c o u r a g e m e n t i n a w a y t h a tr e s p e c ts t h e i r a w a r e n e s s o f t h e s i t u a t i o n i n w h i c ht h e y f i n d t h e m s e l v e s .References

1 . K a s t e n b a u m , A i s e n b e r g , T h e P s y c h o l o g y o f D e a t h . N e wY o rk : S p r i n g e r , 1 9 7 2 .2 . Sp i n e t t a J . Th e d y i n g c h i l d ' s a w a re n e ss o f d e a t h : a r e v ie w .Psy c h o l B u l l , 1 9 9 4; 8 1: 2 5 6 -2 6 0 .3 . B o w l b y J . Lo ss . N e w Y o rk : B a s i c B o o k s , 1 9 8 0 .4 . M c I n t i r e M S . T h e c o n c e p t o f d e a t h i n m i d w e s t e r n c h il d r e na n d y o u t h . A m J D i s C h i l d 1 9 7 2; 1 2 3 : 5 2 7 -5 3 2 .5 . Zw e i g R . C h i l d re n ' s a t t i tu d e s t o w a rd d e a t h . In : Sc h o w a l t e r J ,e d. T h e C h i l d a n d D e a t h . N e w Y o r k : C o l u m b i a U n i v e r s i t yPress , 1983 .6 . B l u e b o n d - L a n g n e r M . T h e P r i v a t e W o r l d s o f D y i n g C h i l dr e n .Pr i n c e t o n : P r i n c e t o n U n i v e rs i t y Pre s s, 1 9 7 8 .7 . G l a se r , S t ra u ss . A w a re n e ss o f D y i n g : A s t u d y o f So c i a lIn t e ra c t i o n . C h i c a g o : A l d i n e , 1 9 6 5 .8 . B l u e b o n d - L a n g n e r M , P e r k e l D , G o e r t z e l E . e t a l. C h i l d r e n ' sk n o w l e d g e o f c a n c e r a n d i t ' s t r e a t m e n t : i m p a c t o f a n o n c o l o g yc a m p e x p e r i e n c e . J Pe d i a t r 1 9 90 ; 1 1 6 (2 ) : 2 0 7 -2 1 3 .9 . B l u e b o n d - L a n g n e r M , P e r k e l D , G o e r t z e l E e t al . P e d i a tr i cc a n c e r p a t i e n t s ' p e e r r e l a t i o n s h ip s : i m p a c t o f a n o n c o l o g yc a m p e x p e r i e n c e . J Psy c h o s o c i a l O n c o l o g y 1 9 91 ; 9 (2 ) : 6 7 -7 9 .

Further readingB l u e b o n d - L a n g n e r M . M e a n i n g s o f d e a t h t o c h i l d r e n . I n : F ei f el H ,e d. N e w M e a n i n g s o f D e a t h . N e w Y o r k : M c G r a w H i ll , 1 97 7.C o r r CA, M c N e i l J N . A d o l e s c e n c e a n d D e a t h . N e w Y o r k :Springer, 1986 .K a r o n M , V e r n i c k J . A n a p p r o a c h t o e m o t i o n a l s u p p o r t o f f a ta l lyi l l ch i ld ren . Cl in Pedia t r 1968; 7 : 274-280 .L o n e U o R . C h i l d r e n ' s C o n c e p t i o n s o f D e a t h . N e w Y o r k : S p r i ng e r ,1980.S p e e ce M , B r e n t S . A c h i l d ' s u n d e r s t a n d i n g o f d e a t h . C h i l d D e v1984; 55 : 1671-1686 .S p i n e t t a J , D e a s y - S p i n e t t a P . L i v i n g w i th C h i l d h o o d C a n c e r . S t .L o u i s: C . V . M o s b y C o m p a n y , 1 98 1.W a e c h t e r E H . C h i l d r e n ' s a w a r e n e s s o f f a t a l i ll n es s . A m J N u r s1979; 71 : 1168-117 2.W a s s H . C h i ld r e n a n d D e a t h I n : K a s t e n b a u m R , K a s t e n b a u m B ,e d s. En c y c l o p e d i a o f D e a t h . A r i z o n a : O ry x Pre s s , 1 9 8 9 .