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How to help children when a loved one passes away during the Covid-19 pandemic?

Pr Richard Delorme, Dr Alexandre Hubert, Dr Emma Barron, Dr Eva Stantiford, Centre of Excellence for Autism and Neurodevelopmental Disorders, Ile de France, Paris, France

Often the death of a loved one is the first real experience of death for a child. It is a difficult ordeal for a person of any age, but it is especially hard for young people. Adults may be unsure of how to meet the needs of children during this time. They may feel overwhelmed by their own grief and have questions about how to explain such a difficult concept in a language that children can understand.


This is especially difficult because it comes at a time of intense family stress related to the Covid-19 lockdown, where there was no prior indication that it could happen so quickly and so suddenly, and where family suffering is also confined.

Children react differently to the death of a loved one depending on their age or stage of development:

· 0 to 2 years: Toddlers cannot understand the concept of death. The loved one is simply no longer there, as if they were abandoned or separated from their caregiver. As a result, a child may react in a variety of ways, such as being clingier towards a parent or else feigning indifference.

· Ages 2 to 6: Pre-school children are beginning to understand the concept of death, they may perceive death as something reversible where the deceased can come back to life (like going to sleep and then waking up). They may imagine that death has something to do with them and think that it is their fault and that they are being punished for somehow misbehaving.

· 6-11 years: School-aged children are able to understand that death is permanent, but they may have difficulty understanding why their loved one should die.

· 12 years and older: Adolescents are fully able to understand that death is irreversible and that everyone close to them can die. However, adolescents still tend to believe that death affects only others.

A child's possible reactions to grief:


· Sadness: The child expresses sadness over the loss of a loved one, which is the most typical reaction to grief.

· Anger: Losing a loved one is not fair. It can lead to anger and irritability directed at themselves or others.

· Increased anxiety: Losing a loved one sends the message that the world is a dangerous and insecure place. As a result, the child may feel anxious and afraid of dying or losing other loved ones, and may become “clingy” towards those who care for him or her.

· Shock/denial: The child is so upset about death and tries to avoid dealing with it. This may include avoiding talking about the loss of the loved one.

· Guilt: In some cases, the child may blame himself or herself for the loss of a loved one. "Maybe if I had behaved better..." "Maybe if I hadn't told grandma I hated her that time..."

· Behavioural issues: the child may withdraw and no longer participate in family activities, no longer follow adult instructions. They may also become aggressive in expressing anger and sadness by being confrontational, provocative and aggressive.

· Acceptance: the child accepts the loss of their loved one, learns to live with it, is able to move on with their life and talk about the death.

How can children be helped when a loved one passes away in a period of lockdown?

The occurrence of the death of a loved one is an important ordeal for children. Parents and the whole family have a major role in the emotional stability of children. Faced with the loss of a loved one, it is only natural that a child would need the person or people who care for them more, and as a result, your child may become more dependant than usual.

· Answer child’s questions; keep your answers short and simple.


· Don't feel obligated to provide all the answers.


· Allow the child to grieve. Note that for some children, real grief may be delayed.


· Listen to what the child has to say and how he or she says it. If desired, talk about the deceased loved one, tell stories about them, their positive or negative feelings about the person (the child may be stuck in the grieving process and may feel anger or guilt about the deceased). For example, "Sometimes we are angry with the people we love. Are you angry with (the person who died)? ».


· Talk honestly about death with your child so they can begin to understand that death is final. Avoid euphemisms, as young children tend to understand things literally (avoid images of rest or sleep - the deceased will not "come back").


· Adapt your language to the child's level of understanding:

- "Grandma got sick and died" can be problematic, because then the child will be preoccupied with getting sick. Instead, continue your explanation by saying "Grandma was so sick that nothing could help her, not even the usual medicines".

- "Grandma went to the hospital and then she died" can be problematic because your child may be afraid that people who go to the hospital will die. Instead, explain "Normally people get better in the hospital, but Grandma was so sick she died”.


· Acknowledge and accept the child's feelings:

- Reassure the child that shock, disbelief, guilt, sadness and anger are normal feelings.

- Do not deny them their feelings, do not say, "Don't be sad" but rather, simply acknowledge their pain and offer support, "Yes, it's sad. It's hard. I love you. Come, give me a hug..."

- Reassure the child by saying:

- That he will always be cared for and loved by an adult,

- That he shouldn't blame himself for the death,

- That he couldn't have prevented the death,

- That he can't bring back the person who died.

- Reassure the child about his or her own situation regarding the illness. Be careful that the child does not become very worried about a risk of infection for him or her or his or her family.


· Be patient and consistent with the answers if the child asks the same questions over and over again.


· Reassure the child about the situation of other people around him/her. The child may fear losing other "old" people. Children often wonder, logically, if they will lose other people they love. The best solution is to say something simple, such as "I expect to be here for a long time".


· Try to continue normal activities as much as possible, given the lockdown, so that children feel that the situation is under control. Don't interrupt family activities and keep up with the daily routine.

Funeral

· Due to the lockdown, the funeral will be held in very unusual sanitary conditions, not allowing all the relatives to attend.


· Opinions are divided as to whether young children should attend the funeral. Children should be with their families during the grieving process, but funerals can be overwhelming for young children.


· Encourage family time for reflection, even if it is in the form of video-conferencing. This may be an acceptable substitute for attending the funeral itself.


· If you want your child to attend the funeral, then review what will happen so that he or she is prepared. Make sure the child is with a calm adult throughout the funeral.


· Prepare the child for the fact that parental tears or sadness are common in these situations and that it is a way to express sadness and pay tribute to the grandparent who has died. Some people will cry, while others may laugh and talk, it is their way of remembering the deceased.


· Allowing the child to place a picture or letter near the casket can sometimes be comforting.

Continuing the grieving process

· Some children find comfort in the days following a death by looking at or even carrying pictures of their loved one. A special toy or memento associated with the deceased may also be comforting.


· A child going through the process of grief may become anxious and dependant or angry and rebellious. They may complain of physical symptoms such as a headache or stomach-ache or have difficulty concentrating during activities you offer at home.


· Sometimes nights are harder with nightmares and difficulty falling asleep. Be tolerant at the very beginning, expressing from the outset that it is a tolerance but that it will not last. After 2 or 3 days, sleep patterns should return to their usual rhythms. Don't hesitate to give him small chance cards; for example, he will have a card every evening with which he can get up and ask for a kiss or a glass of water. If he manages not to use them, then he will be rewarded the next morning.


· Put your foot down on activities that are too strenuous, but keep a pace that will be reassuring. Don't interrupt homework completely, for example, but introduce more pleasant breaks.


· Avoid letting your child take refuge in activities that are too solitary (video games in particular, unless it is for family play; or reading times that are too long). Encourage moments together as a family (if you have the strength) and "quiet" moments when solitude may be acceptable.


· It is normal for a child to be sad, feel anger, anxiety or guilt, or even show behavioural problems when grieving.


· These changes in behaviour will probably disappear within a few weeks. If they do not, the child may need to talk to a psychologist. You can contact psychologists during the lockdown phase. Psychologists can do video-conferencing consultations. These video-conferencing consultations are effective and encourage certain spontaneity, which is not always the case in a consultation in an office that is more frightening.


· Parents, you are not alone in having to deal with your child's sadness. Don't hesitate to ask for help from family and friends or professionals. Even during lockdown, it is possible to contact a psychologist for your child.


· It is important not to allow a taboo to develop around the subject of the deceased. Don't be afraid to mention the person's name and share an occasional memory of the person. This practice reinforces the idea that death is a natural part of life rather than something supernatural and frightening.


· Over time, focus on providing your child with a reassuring environment, as best you can in a confined situation. Active play, humorous games and arranging telephone or video conferencing appointments can really help.


· During this period of mourning, don't hesitate to reduce access to the media that provide ongoing information, which can be particularly distressing for children. This sense of continuity in the crisis increases children's stress considerably. The child wonders if after a loved one, it will be the parents and even him or her. You must reassure them and avoid confronting them with this information or any discussions you may have about the ongoing health crisis.

Death and Religion

· One issue that can be sensitive after a death is religion, especially for interfaith families or families composed of a mixture of believers and non-believers.


· If your child was raised in a religious household, you will probably place the death in a religious context. It is important that the message given to the child be as consistent as possible with your beliefs and the beliefs of those around you.


· On the other hand, if you have not raised your child in a religious context, there is no need to introduce new ideas about God and the afterlife at such a traumatic time. This can be more confusing than comforting.


· In either case, if a child asks difficult questions, it is normal to simply say that you don't have all the answers.


48 Boulevard Serurier, 75019  Paris France

©2020 by Dr. Benjamin Landman. Child Psychiatry, Robert Debre Hospital - Paris