Between travel restrictions and limits on visitors to hospitals, parents may get the news of a loved one's death over the phone and find themselves having to tell children who may be unprepared.
“Not telling them does not protect them”
At the end of March, doctors in the child and adolescent psychiatry group at Oxford University, led by Alan Stein, published an editorial in the journal The Lancet: Child and Adolescent Health, arguing that honest and effective communication with children about the pandemic, including about death and dying, and about parental stress and sadness, was vital for children's psychological health and well-being.
The group has published in the past on how to talk with children about life-threatening illness - their own or that of a parent - emphasizing that the communication needs to be tailored to children's developmental understanding. Parents should not try to keep troubling news from their children, they wrote, nor should they take refuge in overly technical talk, but should acknowledge their own emotional distress without overwhelming the child's emotions or fears with their own.
"Not telling them does not protect them," said one of the authors, Louise Dalton, a consultant clinical psychologist in the department of psychiatry at Oxford, who led the project together with Elizabeth Rapa, a senior postdoctoral researcher. "Even young children are aware of the changes that have happened in everyone's life."
How to break bad news
The group had developed guidance for the health care workers who found themselves in the new pandemic position of having to deliver bad news by phone, and they worried, Rapa said, that family isolation during the pandemic meant that "children would be even more invisible." So their guidelines emphasized the importance of finding out whether the deceased person left children who would need to be told, and offering help to the family member who would have to do the telling.
They wrote guidance for the family member who has to do the telling, which Rapa called "a step-by-step guide to help parents or any adults have one of the most difficult conversations you're ever going to have with your child." The specific scenario they had in mind was a parent, at home in lockdown with one or more children, getting a phone call that a grandparent or other family member had died, though their advice applies to many other situations.
"Parents were taking this horrendous phone call to learn that granddad had died," Rapa said. "Children would know that granddad was not very well, they would know in lockdown that mum has taken this phone call - you would have hardly any time to prepare." The first instruction for parents is to take a minute to breathe "as slowly and deeply as you can."
"Thinking about talking to children about this probably feels the hardest thing in the world," the guide begins. "Try to keep your focus on the next few minutes and how you want the children to hear the news of their loved one's death."
It's a conversation that changes with the age and understanding of the child, but remember that children as young as 2 will understand that something has happened, Rapa said, and will need to be included.
Be prepared for questions
Dr. Elena Lister, an adult and child psychiatrist on the faculty at Columbia and Cornell medical centers who specializes in grief and loss, said, "I'm a believer in no rush, holding your child, being close to your child, letting that sink in for a few seconds, waiting to see what comes up."
Answer the specific questions a child asks, Lister said, for example about the actual cause of death: "The doctors couldn't help her with her breathing enough." And let the child know, "We're going to have a lot of time to talk about this, we'll get through this together."
Be prepared for common reactions, including being asked if you are going to die as well. Especially with younger children, be ready to revisit the topic, check in with them a day later, and ask them what they understand, Rapa said.
"I don't think of it as one conversation," said Lister, who has written about the experience of losing her daughter to leukemia. "It's step one of a difficult conversation."
Use literal language
Use very specific and literal language. Young children may hear "we've lost granddad," for example, and assume that the next step is to go find him.
Make sure that children are not blaming themselves, Dalton said. That may mean reassuring the child that the person who died was well taken care of in the hospital, that everyone did everything that could be done. Talk about practical measures to prevent transmission - masks and hand hygiene. Talk about the scientists who are working on vaccines.
Acknowledge your own sadness, and that you miss the person who has died.
Parenting through loss
We're living in a world right now where experts on grief and loss have a lot to teach us about everyday parenting. Our behaviour as parents is already affected by the stress of the pandemic, both acute and chronic, Lister said. "The acute part puts us all in a state of hyper-arousal," she said, but the chronic stress is particularly wearing.
"Kids are seeing loss in many different ways," Lister said. Their schools, their friends, their routines, their summer plans - and then on top of that, the constant talk about disease and death. "They're surrounded by it - in the news, their parents are talking about it - it's so unlike regular life where we all chug along at a kind of level of denial of our mortality," Lister said. "This environment has caused us all to live in a soup of mortality awareness."
Children are scared and anxious, Lister said, and they may be encountering misinformation, or misunderstanding some of what they see and hear. Bring up the difficult topics with your children, she advised. Try not to discuss them at bedtime, and remember that what you say to one sibling may well be passed along to the next. Having these conversations, she said, "teaches them you can handle the hard stuff - they feel less alone."
Adapt honesty to age
Again, be prepared for conversations about whether you - or some other family member - will die from the virus. How you answer that, of course, will depend on the child's age. For a 4-year-old, you might say, "I wash my hands," Lister said, "I am healthy, I am doing everything I can to stay as well as possible." Go into more detail for older children, but "you cannot guarantee what you cannot guarantee."
Especially after someone has died, "the full range of emotional reactions is entirely normal," Dalton said. Children may have increased anxiety, including separation anxiety, may be unusually clingy, or overreact emotionally to small events. But if a child is consistently withdrawing, refusing to take part in activities that usually give pleasure and comfort, the child may need more help. Children's emotional distress often shows up in disturbances of eating or sleeping, but persistent behavioral changes may warrant a talk with your pediatrician or a referral for mental health services.
"We need to be honest and specific with children - as adults, we have to be courageous," Dalton said.