Whether conducting on-site triage, counseling survivors in the emergency room or contending with the short- and long-term suffering of their patients, families and communities, pediatricians must treat and comfort while coping with their own horror, grief and loss.

Stunning as school violence is, it accounts for only part of the U.S. pediatric disaster picture. Nature is at fault, too, according to information gathered since the 1974 enactment of the federal Disaster Relief Act.

Over the last 24 years, Americans have endured more than 800 major disasters, with more than 8,000 deaths each year from either human-created situations, like the Oklahoma City bombings, or natural calamities, like the storms unleashed by El Nino, according to the U.S. Department of Health and Human Services (HHS) data.

When children survive a disaster and sustain a significant loss, such as the death of a parent, sibling or friend, they need help in handling their grief. Pediatricians all too often find themselves first in line to deal with the aftershocks of such emergencies.
 

A grip on grief 

Before offering advice, the pediatrician must assess the family as well as the incident that caused the grief, advised David R. DeMaso, M.D. He is the American Academy of Child and Adolescent Psychiatry's liaison to the Academy. He also serves as associate psychiatrist and chief, Department of Psychiatry, Children's Hospital, Boston, and associate professor of psychiatry at Harvard Medical School, Boston. 

"You want to get a real sense of the family and the child sitting in front of you," said Dr. DeMaso, who has been working with bereaved families for 20 years. He suggested the pediatrician ask questions like these:

 
• How does the family function in general? 
• What is the parents' understanding of what has happened? 
• What is their child like? 
• What was the child's relationship with the person who died? 
• Has the child or family experienced other losses or previous deaths? 

Dr. DeMaso emphasized that successful resolution of the grieving process depends on family cohesion, support and communication, and the pediatrician should stress the importance of this to the family. He suggested family routines be upheld as much as possible to give children a sense of stability. 

Parents should not try to hide their grief, he continued, because children need to know that showing feelings is normal and helpful. "Parents are always afraid of breaking down in front of their children, afraid it might scare them," Dr. DeMaso said. "But it really doesn't. It lets them know that this is something sad, and that feeling sad about it is OK." 
 

Keep it age-appropriate

Children at different ages view death differently, so discussions about death must be tailored to the child's age.

Until age 2 years, children don't have a cognitive understanding of death, although they do experience separation anxiety. Parents should never tell children that the person who died "went to sleep" or "went on a trip." 

At ages 2 to 5 years, children view death as reversible and temporary. They believe in magical thinking, that wishes come true, Dr. DeMaso explained. If they are mad at a friend who later dies, they may believe they caused the death. Guilt is pervasive at this age and must be addressed.

Even after parents explain death truthfully, the young child may persist in believing that the person will return. Parents shouldn't feel compelled to fight this, he said. "They could say, 'Wouldn't that be nice,' and leave it at that." 

Young children anchored in the present by an immature conception of time worry that death will occur in the next few hours or days. For example, a child might ask, "Mommy, will you die too?" Dr. DeMaso recommends a reassuring response like this: "Nobody is going to die right now. We are going to take care of you; everything is going to be O.K." 

By ages 5 to 10 years, children are becoming much more aware of the irreversibility and inevitability of death. They tend to interpret death as a person coming to take them away, such as the Grim Reaper or an angel. 

They have concrete reasoning, so they may be interested in the details of the burial and the biological aspects of death. They realize that their parents will die someday, but view their own death as far off. After age 10 years, children develop abstract reasoning and really begin to understand death as an adult does, Dr. DeMaso said. They know that all people die and that they will die someday, too, but they think of it as something in the distant future. 

Sadness and grief stem from losses other than death, added Dee Hodge III, M.D., FACEP, FAAP, associate director for clinical affairs in the Department of Emergency Medicine, St. Louis Children's Hospital, St. Louis. 

He was working at Oakland Children's Hospital when the Oakland-Berkeley Hills firestorm erupted in October 1991, destroying 3,800 homes and killing 25 people. He also lived in Los Angeles during the 1989 Loma Prieta and 1994 Northridge earthquakes. 

In these disasters, he saw a great deal of suffering caused, not only by death, but by property loss and displacement. "These people saw their whole world torn apart," he said. 
 

Eyewitness to violence 

Children react to death and loss in a wide variety of ways. They may feel shock and numbness, sadness, anger, guilt, or transient unhappiness, the experts agreed. 

They might keep concerns inside, become increasingly clingy with their caregivers or exhibit disobedience, lack of interest in school, sleep disturbance, physical complaints, decreased appetite or regression.

Children who witness violence often have symptoms of post-traumatic stress disorder, noted Jane F. Knapp, M.D., FAAP, director of the division of emergency medical services, Children's Mercy Hospital, Kansas City, Mo. 

They re-enact the stressful event repetitively in their play. They may experience trauma-specific nightmares or flashbacks. They can't stop thinking about the event, or something triggers those thoughts, she explained. 

They may feel distress during events that resemble or symbolize the disaster, and they may routinely avoid reminders of the event or show general lack of responsiveness. 

These children also display regression: going back to sucking their thumb, wetting the bed or using a bottle. 

Clinging is common, especially among younger children. "This was noted a lot after the Oklahoma City bombing," Dr. Knapp said. "The kids don't want to be left alone, and they are sort of hanging off their parents."

Physicians need to ask the child how he or she is feeling and also must ask the parents for their impressions of how the child is feeling. 

"You have to ask both," Dr. Knapp emphasized, "because sometimes parents don't pick up on how much the child is suffering." 

She asks parents about the following signs in their children: headaches, stomachaches, nausea, vomiting, anxiety, feelings of guilt, clinging to adults, being secretive, sad, moody, obsessive, withdrawn, argumentative, nervousness. 

She then asks the child questions like these: 

• Do you feel worried? 
• Do you get upset when you think about what happened? 
• Do you think about it over and over? 
• Do you feel jumpy and scared? 
• Do you have bad dreams or trouble sleeping? 
• Do you not want to go to school? 
• Do you feel bad? 
• Do you not want to play?

To help children deal with their grief after a traumatic event, she recommends the use of "psychological first aid," which uses drawing, storytelling and workbook activities to help children come to terms with their experience. 

"Early intervention seems to make a big difference," she said, concluding that the onus is on pediatricians to identify these children and refer them for mental health services. 
 

AAP resources Work Group on Disasters and the U.S. Department of Health and Human Services. Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician. 1995. Free from National Mental Health Services Knowledge Exchange Network, P.O. Box 42490, Washington, DC 20015; phone (800) 789-2647.  Committee on Pediatric Emergency Medicine. "Death of a Child in the Emergency Department." Pediatrics. 1994; 93:861-862.  Committee on Psychosocial Aspects of Child and Family Health. "The Pediatrician and Childhood Bereavement." Pediatrics. 1992:89:516-518.  Diane M. Komp, M.D., FAAP. "A Window to Heaven: When Children See Life in Death." 1992. Zondervan Publishing House, Grand Rapids, MI 49530.

Doctors all too familiar with grief

One of the hardest parts of being a pediatrician is dealing with unexpected death and destruction, especially that inflicted on children. After a disaster strikes, both patients and physicians might benefit from critical incident stress management (CISM).

Many hospitals now have CISM teams to help health care professionals deal with their emotional responses to traumatic incidents, such as the death of a child, reported Susan Fuchs, M.D., FAAP. She is chair of the AAP Section on Emergency Medicine and associate director of pediatric emergency medicine at Children's Memorial Hospital in Chicago. One component of CISM is debriefing, especially as a group intervention. A typical hospital debriefing session, led by a specially trained team, lasts several hours. Attendees might include doctors, nurses, social workers, chaplains, parents, paramedics, firefighters, police and any others involved in the event. "A lot of tissues get passed around at these meeting," she said.

According to Jane Knapp, M.D., FAAP, "It is not a finger-pointing process," but rather a forum where people talk about what they saw and how they felt. 

"It helps you to start to work through your own feelings, to look for ways to deal with them and then come to closure," Dr. Knapp said. 

The usefulness of critical stress incident management is not limited only to disasters. Dee Hodge III, M.D., FAAP, remembered a 3-year-old girl who came through the emergency room at his hospital in St. Louis. She had been severely abused and graphically mutilated. The hospital staff were shaken enough to request a critical stress incident debriefing team. "It really had a profound effect on our staff," Dr. Hodge said. 

Debriefing teams also can be sent to schools, churches or other facilities after a disaster, accident or other incident to give the children involved an outlet for their feelings, a chance to discuss and ask questions about what happened. 

If a pediatrician lives in a community that does not have a CISM team, he or she can get the ball rolling to create one. One way to begin is to call the International Critical Incident Stress Foundation, at (410) 750-9600. It is an organization in Ellicott City, Md., that helps set up CISM teams worldwide. About 700 teams exist right now.

"As first aid is to surgery, CISM services are to the whole field of psychotherapy," said Jeffrey T. Mitchell, Ph.D., foundation president. Mitchell is a clinical associate professor of emergency health services at the University of Maryland and a certified trauma specialist. "The job is to get in while the situation is acute and basically to stabilize it."

Besides saving mental health, CISM seems to save money. Mitchell cited a study showing that for every $1 the Canadian government invested in creating and maintaining a CISM program for rural nurses, it saved $7.09, accrued in less personnel turnover, less sick time used and fewer disability claims.

Physicians might tend toward believing they are immune to post-traumatic stress, but group or even one-on-one CISM often can be helpful. "A lot of them have the sense, 'You know, I really don't need help - everybody else does,'" Mitchell said. "But, once they get on board, they realize they do have these needs - they're not exempt."
 
 

 Reprinted with permission of AAP News, May 1998, (Volume 14, Number 5, pages 1,8) the official newsmagazine of the American Academy of Pediatrics