Grace Christ, an expert on childhood bereavement, has witnessed through years of work with cancer patients the emotional hurricane of anger, sadness, anxiety, fear and emptiness that children experience as they cope with the death of a parent. A faculty member at the Columbia School of Social Work, Christ has written a new book on how children grieve a parent who has died from cancer, based on her groundbreaking study of cancer patients and their families. She says children experience and express grief quite differently from adults and their reactions to death vary considerably, depending on their development.
Christ said there are two common views of how children cope with the death of a parent. "One is that children will be irrevocably damaged by this experience and therefore they should not be informed," she said. "The alternative is that children are resilient and will bounce back on their own from this tragedy. Our research showed that grieving is a painful process at any age but children can learn and grow with the help of informed and supportive adults."
For surviving parents, relatives, teachers, and other professionals trying to help these children, their powerful expressions of grief -- a six-year-old, longing for her mother, expresses thoughts of suicide; the shock expressed by a nine-year-old when she fails to see her late father watching her soccer game from the bleachers, as he always did; a teenager who refuses to talk at all about his late father and is heard sobbing at night in his room -- may not be recognized as typical reactions to death.
When a surviving parent fails to understand this grief, the result for both parent and child may be heightened fear, confusion and helplessness. To help parents and others understand how children experience and express grief Christ in 1988 began an unprecedented study of children whose parents were cancer patients at Memorial Sloan-Kettering Cancer Center in New York City. For six months before and 14 months after the deaths of their parents, 157 children, ages three to 17, and their families met with social workers and other mental health professionals in their homes for counseling and therapeutic intervention. These sessions over a period of seven years produced more than 1000 audiotaped interviews. With 88 participating families, Christ's was the largest intervention study of childhood bereavement and the most comprehensive ever; previous studies of the kind had only evaluated children after their parent died, often years later, and none during the period of illness that led to death. It is estimated that sudden death accounts for only one-quarter of the deaths of parents of children under 17, while the anticipated death of a parent is the more common experience of children..
"Because we talked with them, their parents, and their siblings at length, before and after the death, we had a more complete understanding of the parent's terminal illness and the death and how the families were able to reconstitute themselves," said Christ (pronounced krist), whose book, Healing Children's Grief: Surviving a Parent's Death from Cancer,, is out this month by Oxford University Press. The book describes how the children and their families coped with death and provides practical guidance in several areas, including how surviving parents informed children about details of the illness, prepared them for imminent death, and helped them to create memorials to their parent who died.
In her study Christ found that 83 percent of the 157 children had returned to normal functioning -- in their schoolwork, within their family, psychologically and emotionally -- a little more than a year after their parent died. Some of these children resumed normal functioning even sooner -- within eight months of the death. "Having adults who respect and respond to their grief and who take into account their unique expressions of it is important if a child is to return to normal functioning after a parent's death," said Christ.
Christ also found that the sense of uncertainty during the period of illness leading to the parent's death produced more of an emotional maelstrom for children than the immediate period following death. Christ said: "During the parent's illness, many children couldn't comprehend what might happen in the future. Many imagined and feared utter catastrophe. Although death is terrible, children realized that their lives goes on. They returned to school and continued to have friends and interests that distracted them. So for them it felt as if things could have been worse."
At the time that she began her research, Christ had been director of the Social Work Department at Memorial Sloan Kettering Cancer Center for 12 years. As she worked with cancer patients and their families and saw how they became overcome by turmoil, worsening crises and fear of the inevitable, she searched for meaningful interventions. In counseling families with a terminally ill patient, Christ said parents of multi-aged children would often tell her: "'They are all behaving quite differently. How can I understand what they are experiencing? How can I help each of them cope?'"
"We used our experience the best we could," said Christ, "but I felt we needed to understand how children experience the death of a parent in a much more systematic way to see if we could give better answers to what is typical, what is normative for children at different developmental levels."
She began by dividing the 157 children in her study into five multi-age groups -- 3-5, 6-8, 9-11, 12-14 and 15-17 -- based on similar levels of cognitive, social and emotional development. "What was most surprising," said Christ, "was that there really were quite distinct differences in terms of how children at different developmental levels felt, experienced and expressed their grief and you had to understand this in order to help the children effectively."
Three-to-five-year-olds, said Christ, cannot anticipate the loss of a parent and do not immediately understand that the parent will never return. "Two to three months later," said Christ, "they still ask when mommy or daddy will be back." With time, this age child understands that the parent will not be back. Their goal then becomes the restoration of the family to its "normal" state. "The children demand that the surviving parent remarry quickly to create a new family like their old one," said Christ. "One girl suggested to her mother that next time she should acquire two "daddies," in case they lose one again.
Six-to-eight-year-olds often put together events and facts that do not belong together -- a process known as magical thinking. Christ cites the example of a 7-year-old girl who prayed that her mother's pain would stop the night before she died. "When she spoke to the social worker the next day, she said, 'I think I killed her,' said Christ. "Children at this stage need a lot of help dealing with the erroneous ideas they develop." Another characteristic of children this age, Christ said, is what she describes as "the joyous remembrance" of their dead parent. "They want to look at pictures of the parent, talk about the things they did together and recall their joy with the parent." Surviving parents who are experiencing deep sorrow can find such joy disturbing and surprising, says Christ.
Nine-to-11-year-old children are beginning to master the world through facts and information. Because they understand more, they can become overwhelmed by feelings when a parent is dying or dies, and are unable to express these emotions. "These children become very angry when left out of discussions," Christ said. "They want to know as much as they can about the illness or death as a way to bring more control to the experience. Parents should honor this need for information. As a way to soothe the intense feelings that they cannot easily express, children in this age group want and need to find more formal ways to memorialize the parent. One 10-year-old, said Christ, became intensely emotional after finding her mother's handbag. She and her father later were able to calm the intensity of this discovery by a ritual of bringing balloons to the grave and releasing them.
Children ages 12 to 14 are beginning to separate from their parents, becoming more independent and developing a sense of their own identity. "It was enraging to them at that moment to have their parents withdraw from them -- and very frightening," said Christ. Young teenagers normally focus intently on themselves and can be self-absorbed to the point of harshly excluding others' feelings . "In the context of enormous stress, children, like adults, have very exaggerated responses," said Christ. She recalled one teenager who, during her father's illness, told her mother, "'Well, if he can go to his chemotherapy, why can't he take me to my party?'" Because 12-to-14-year-olds understand death in broader perspective, said Christ, they can become overwhelmed with emotion. "They were very frightened of public displays of emotion and focused throughout the dying process and death on controlling their emotions," she said. Among this group, too much information was seen as intrusive. "It brought up the pain they found difficult to acknowledge," said Christ. These teenagers would commonly say: "I cry in my room alone."
Fifteen-to-17-year-olds begin to describe the intense sense of loss and emptiness that adults feel after the death of a spouse. "Because they had developed an internal image of the parent, they experienced a sense of loss of self as well as the loss of the parent," said Christ. The grief experienced by older teenagers was closer to the adult experience but it did not last as long.
Children have different views of their deceased parent at different ages, says Christ. In their minds, children maintain an ongoing relationship with the parent that changes over time. The mother of one girl, whose own father died when she was two, remarried when the girl was seven, said Christ. The girl told her stepfather that she very much wanted him to be her father but that he would have to understand that he would always be number two in her heart. As a nine-year-old, she sent well-wishes to President Reagan when he underwent cancer surgery and, recalling her own father's experience, hoped that new treatments since then would help the president. "As she developed, her understanding of the meaning of her father's death evolved with her," said Christ.
How does a parent know when a child cannot cope with such overwhelming emotions? Christ points out that intense emotion that continues for a long period is an obvious danger sign. She said younger children, especially six-to-eight-year-olds, frequently expressed longing for the parent by saying they wished they could die, too. "We learned that most of the time what they meant was not that they wished to kill themselves but that they wanted to be with their parent," she said. If this expression is transient, it is viewed as part of the normal process. If children become preoccupied with this feeling, and their functioning otherwise declines, then it may signal a need for professional evaluation.
Christ emphasizes the importance of sharing appropriate information with children about death and dying. She recounts a devastating story that unfolded as she viewed a television talk show interview with an eminent author. The author said when he was a young child, he was sent away from home to stay with relatives. When he returned home a few months later, he was told his mother was away on a trip but would return soon. As the months became years, he often cried alone at night wondering what he had done to keep his mother away. Many years later, he discovered that she had died of cancer. He described his anger at his family for the deception, which caused years of guilt and self-recrimination. While an extreme example, Christ says it is not an uncommon story and illustrates an essential point about helping children to cope with their powerful emotions.
"It is hard to overestimate the value children place on information," said Christ.
As a social worker, Christ's thinking about the impact of a parent's death on children was influenced by her earlier work with disturbed children and adolescents whose early development was marked by emotional separation from their mothers. The history of her own family also led her to focus on this issue. Her grandmother died at age 26 from Hodgkin's disease, leaving three young children, including her mother, then 5.