5. Specific Interventions

5.3. Counseling Interventions According to Age

The general recommendations provided by the Pan American Health Organization for children and adolescent psychosocial care in a disaster situation can be found in the Appendix page 39. The chart describes the recommendations for parents and teachers for sleep disorders, excessive clinging, incontinence, regressive behaviors, school problems, anxiety, aggressiveness, rebellious, hostile and reckless behavior, pain and somatic complaints, and bereavement.

An understanding of how children may view death and adjust to loss is critical to providing psychosocial counseling and care. As described in Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians, children’s understanding of death may be very different from that of adults. Children have had far less personal experience of loss and have accumulated less information about death. They can also have difficulty understanding what they have seen and what they are told unless the basic concepts related to death are explained to them. Adults will need to provide especially young children with both the basic facts about what happens to people after they die, as well as the concepts that help them to explain those facts. For example, young children may be told that after people have died, their body is buried in a cemetery or turned to ashes that can then be buried or scattered. Children can be very distressed by these facts unless they are helped to understand the concept that at the time of death, all life functions end completely and permanently—the body can no longer move, and the person is no longer able to feel pain. That is why it is okay to bury or cremate the body.

Children need to understand four concepts about death to comprehend what death means and to adjust to a personal loss: irreversibility, finality, inevitability, and causality (Table 2). Most children will develop an understanding of these concepts between ages 5 and 7, but this varies widely among children of the same age or developmental level, based in part on their experience and what others have taught them. When faced with a personal loss, some children 2 years old or younger may demonstrate at least some comprehension of these concepts. Adults should not underestimate the ability of young children to understand what death means if it is explained to them properly. Therefore, it is best to ask children what they understand about death, instead of assuming a level of comprehension based on their age. As children explain what they already understand, it will be possible to identify their misunderstandings and misinformation and to correct them accordingly.

TABLE 2. Concepts of death and implications of incomplete understanding for adjustment to loss

Irreversibility
Concept Death is seen as a permanent phenomenon from which there is no recovery or return.
Example of incomplete understanding Child expects the deceased to return, as if from a trip.
Implication Failure to comprehend this concept prevents child from taking the first step in the mourning process, that of appreciating the permanence of the loss and the need to adjust ties to the deceased.
Finality (Nonfunctionality)
Concept Death is seen as a state in which all life functions cease completely.
Example of incomplete understanding Child worries about a buried relative being in pain or trying to dig himself or herself out of the grave; child wishes to bury food with the deceased.
Implication Can lead to preoccupation with physical suffering of the deceased and may impair readjustment; serves as the basis for many horror stories and films directed at children and youth (e.g., zombies, vampires, and other “living dead”).
Inevitability (Universality)
Concept Death is seen as a natural phenomenon that no living being can escape indefinitely.
Example of incomplete understanding Child views significant individuals (i.e., self, parents) as immortal.
Implication If child does not view death as inevitable, he or she is likely to view death as a punishment (either for actions or thoughts of the child or the deceased), leading to excessive guilt and shame.
Causality
Concept A realistic understanding of the causes of death is developed.
Example of incomplete understanding Child who relies on magical thinking is apt to assume responsibility for death of a loved one by assuming bad thoughts or unrelated actions were causative.
Implication Tends to lead to excessive guilt that is difficult for child to resolve.

When providing explanations to children, use simple and direct terms. Be sure to use the words “dead” or “died” instead of euphemisms that children may find confusing. If young children are told that the person who died is in “eternal sleep,” they may expect the deceased to later awaken and be afraid to go to sleep themselves. This description does little to help children understand death and may cause more confusion and distress.

Religious explanations can be shared with children of any age, but adults should appreciate that religious explanations are generally very abstract and therefore difficult for young children to comprehend. It is best to present both the facts about what happens to the physical body after death, as well as the religious beliefs that are held by the family. Even when children are given appropriate explanations, they still may misinterpret what they have been told. For example, some children who have been told that the body is placed in a casket worry about where the head has been placed. After explanations have been given to children, it is helpful to ask them to review what they now understand about the death.

It is also helpful for children to find their own unique way of saying goodbye to someone they have lost; this can be achieved through painting, planting and caring for a tree, praying, lighting a candle, or any other suitable expression. The permanence of the situation can be supported over time.