community is immune
to catastrophe, but when children are involved - as in the Jonesboro,
schoolyard slayings in April, the fatal Paducah, Ky., prayer group
in December, or the Pearl, Miss., school killings in October - the
and psychic toll are compounded.
triage, counseling survivors in the emergency room or contending with
short- and long-term suffering of their patients, families and
pediatricians must treat and comfort while coping with their own
grief and loss.
as school violence
is, it accounts for only part of the U.S. pediatric disaster picture.
is at fault, too, according to information gathered since the 1974
of the federal Disaster Relief Act.
last 24 years,
Americans have endured more than 800 major disasters, with more than
deaths each year from either human-created situations, like the
City bombings, or natural calamities, like the storms unleashed by El
according to the U.S. Department of Health and Human Services (HHS)
a disaster and sustain a significant loss, such as the death of a
sibling or friend, they need help in handling their grief.
all too often find themselves first in line to deal with the
of such emergencies.
grip on grief
the pediatrician must assess the family as well as the incident that
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
as associate psychiatrist and chief, Department of Psychiatry,
Hospital, Boston, and associate professor of psychiatry at Harvard
want to get a real
sense of the family and the child sitting in front of you," said Dr.
who has been working with bereaved families for 20 years. He suggested
the pediatrician ask questions like these:
he urged. Then, armed with this background, the pediatrician can
does the family function
the parents' understanding
of what has happened?
their child like?
was the child's relationship
with the person who died?
child or family experienced
other losses or previous deaths?
that successful resolution of the grieving process depends on family
support and communication, and the pediatrician should stress the
of this to the family. He suggested family routines be upheld as much
possible to give children a sense of stability.
should not try
to hide their grief, he continued, because children need to know that
feelings is normal and helpful. "Parents are always afraid of breaking
down in front of their children, afraid it might scare them," Dr.
said. "But it really doesn't. It lets them know that this is something
sad, and that feeling sad about it is OK."
ages view death differently, so discussions about death must be
to the child's age.
age 2 years, children
don't have a cognitive understanding of death, although they do
separation anxiety. Parents should never tell children that the person
who died "went to sleep" or "went on a trip."
2 to 5 years,
children view death as reversible and temporary. They believe in
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.
is pervasive at this age and must be addressed.
after parents explain
death truthfully, the young child may persist in believing that the
will return. Parents shouldn't feel compelled to fight this, he said.
could say, 'Wouldn't that be nice,' and leave it at that."
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,
will you die too?" Dr. DeMaso recommends a reassuring response like
"Nobody is going to die right now. We are going to take care of you;
is going to be O.K."
5 to 10 years,
children are becoming much more aware of the irreversibility and
of death. They tend to interpret death as a person coming to take them
away, such as the Grim Reaper or an angel.
have concrete reasoning,
so they may be interested in the details of the burial and the
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
reasoning and really begin to understand death as an adult does, Dr.
said. They know that all people die and that they will die someday,
but they think of it as something in the distant future.
and grief stem
from losses other than death, added Dee Hodge III, M.D., FACEP, FAAP,
director for clinical affairs in the Department of Emergency Medicine,
St. Louis Children's Hospital, St. Louis.
working at Oakland
Children's Hospital when the Oakland-Berkeley Hills firestorm erupted
October 1991, destroying 3,800 homes and killing 25 people. He also
in Los Angeles during the 1989 Loma Prieta and 1994 Northridge
saw a great deal of suffering caused, not only by death, but by
loss and displacement. "These people saw their whole world torn apart,"
react to death
and loss in a wide variety of ways. They may feel shock and numbness,
anger, guilt, or transient unhappiness, the experts agreed.
might keep concerns
inside, become increasingly clingy with their caregivers or exhibit
lack of interest in school, sleep disturbance, physical complaints,
appetite or regression.
who witness violence
often have symptoms of post-traumatic stress disorder, noted Jane F.
M.D., FAAP, director of the division of emergency medical services,
Mercy Hospital, Kansas City, Mo.
re-enact the stressful
event repetitively in their play. They may experience trauma-specific
or flashbacks. They can't stop thinking about the event, or something
those thoughts, she explained.
during events that resemble or symbolize the disaster, and they may
avoid reminders of the event or show general lack of
children also display
regression: going back to sucking their thumb, wetting the bed or using
is common, especially
among younger children. "This was noted a lot after the Oklahoma City
Dr. Knapp said. "The kids don't want to be left alone, and they are
of hanging off their parents."
need to ask
the child how he or she is feeling and also must ask the parents for
impressions of how the child is feeling.
have to ask both,"
Dr. Knapp emphasized, "because sometimes parents don't pick up on how
the child is suffering."
the following signs in their children: headaches, stomachaches, nausea,
vomiting, anxiety, feelings of guilt, clinging to adults, being
sad, moody, obsessive, withdrawn, argumentative, nervousness.
asks the child
questions like these:
likely to be noted by both parent and child are nightmares and trouble
sleeping, Dr. Knapp said.
get upset when you
think about what happened?
think about it over
feel jumpy and scared?
have bad dreams or
not want to go to
not want to play?
with their grief after a traumatic event, she recommends the use of
first aid," which uses drawing, storytelling and workbook activities to
help children come to terms with their experience.
to make a big difference," she said, concluding that the onus is on
to identify these children and refer them for mental health
Group on Disasters and
the U.S. Department of Health and Human Services. Psychosocial
for Children and Families in Disasters: A Guide for the Primary Care
1995. Free from National Mental Health Services Knowledge Exchange
P.O. Box 42490, Washington, DC 20015; phone (800) 789-2647.
on Pediatric Emergency
Medicine. "Death of a Child in the Emergency Department." Pediatrics.
Aspects of Child and Family Health. "The Pediatrician and Childhood
M. Komp, M.D., FAAP.
"A Window to Heaven: When Children See Life in Death." 1992. Zondervan
Publishing House, Grand Rapids, MI 49530.
familiar with grief
the hardest parts
of being a pediatrician is dealing with unexpected death and
especially that inflicted on children. After a disaster strikes, both
and physicians might benefit from critical incident stress management
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,
Susan Fuchs, M.D., FAAP. She is chair of the AAP Section on Emergency
and associate director of pediatric emergency medicine at Children's
Hospital in Chicago. One component of CISM is debriefing, especially as
a group intervention. A typical hospital debriefing session, led by a
trained team, lasts several hours. Attendees might include doctors,
social workers, chaplains, parents, paramedics, firefighters, police
any others involved in the event. "A lot of tissues get passed around
these meeting," she said.
to Jane Knapp,
M.D., FAAP, "It is not a finger-pointing process," but rather a forum
people talk about what they saw and how they felt.
helps you to start
to work through your own feelings, to look for ways to deal with them
then come to closure," Dr. Knapp said.
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
room at his hospital in St. Louis. She had been severely abused and
mutilated. The hospital staff were shaken enough to request a critical
stress incident debriefing team. "It really had a profound effect on
staff," Dr. Hodge said.
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
in a community that does not have a CISM team, he or she can get the
rolling to create one. One way to begin is to call the International
Incident Stress Foundation, at (410) 750-9600. It is an organization in
Ellicott City, Md., that helps set up CISM teams worldwide. About 700
exist right now.
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
a certified trauma specialist. "The job is to get in while the
is acute and basically to stabilize it."
health, CISM seems to save money. Mitchell cited a study showing that
every $1 the Canadian government invested in creating and maintaining a
CISM program for rural nurses, it saved $7.09, accrued in less
turnover, less sick time used and fewer disability claims.
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
'You know, I really don't need help - everybody else does,'" Mitchell
"But, once they get on board, they realize they do have these needs -
of AAP News, May 1998, (Volume 14, Number 5, pages 1,8) the
newsmagazine of the American Academy of Pediatrics