key: cord-1005872-d2txxjqd
authors: Rapa, Elizabeth; Dalton, Louise; Stein, Alan
title: Talking to children about illness and death of a loved one during the COVID-19 pandemic
date: 2020-06-04
journal: Lancet Child Adolesc Health
DOI: 10.1016/s2352-4642(20)30174-7
sha: cb4329443ac239206d141512286241e8a7570ea2
doc_id: 1005872
cord_uid: d2txxjqd

nan

Talking to children about illness and death of a loved one during the COVID-19 pandemic

In the midst of the devastating death toll and hospitalisations from COVID-19, the psychological effect of this unfolding pandemic on children has been unconscionably overlooked. The overwhelming media coverage and barrage of public health messages sustain a high level of physical and emotional threat within our communities, which is intensely observed by children.

Age-appropriate explanations are paramount to ensure children have a coherent narrative and emotional support for their experiences. 1 This need is magnified when someone in the family is hospitalised for or dies from COVID-19. COVID-19 predominantly affects adults, with patients treated in deliberate isolation from friends and family. As a result, children with whom the patient has important relationships are invisible to health-care staff. Crucially, the quality of communication with children about life-threatening illness and death has a longterm effect on their psychological wellbeing and family functioning. [2] [3] [4] Therefore, health-care professionals need to identify affected children to promote and facilitate effective communication within the family. The diversity of family and social structures means that hospital staff contacting relatives should assume that the patient has an important role in a child's life.

Such communication must be tailored to children's evolving developmental understanding of illness and death. 5 Even though most children under 3 years have yet to acquire a complete understanding of death, they are still susceptible to the effect of serious illness or death within the family. Children are astute observers of their environment; within the first year, infants respond to changes in the behaviour and mood of their close caregivers. Children under the age of 2 years become distressed when caregivers leave and seek their return. At 3-4 years children understand death as a departure but might not yet grasp the concept of irreversibility (ie, after death a person cannot be made alive again). Therefore, following a bereavement, it is important to gently repeat the key message that the dead person will not, and cannot, return. By the age of 5-6 years, children appreciate the finality and irreversibility of death and recognise their own personal mortality, but it is not until around age 10 years that children acquire a fully mature comprehension of death.

Similarly, children's understanding of illness causality and transmission emerges over time. Of particular importance are the dual influences of magical thinking (that thoughts and beliefs can cause external events) 1 and children's developing sense of conscience and responsibility. Combined with a basic comprehension of how illness is transmitted, children can easily misattribute the cause of the illness and blame themselves (eg, illness is a punishment for their poor behaviour). 6 Even during adolescence, insufficient or distorted information about a sudden or unexpected death can result in feelings of regret and guilt about causing or not preventing a parent's death. 7 Children's specious feelings of responsibility might be exacerbated in the context of widespread public health messaging about behaviours such as hand washing to prevent the spread of COVID-19. Communication should be concrete and specific to avoid incorrect inferences or misunderstandings about how and why someone became ill or died. 8 Euphemisms are often used to soften sharing the news of a death, but these can create confusion for children who interpret these literally-eg, "We lost Grandpa last night" could be understood by a child that Grandpa can be found again.

Adults instinctively want to protect children from distress, especially when they themselves are worried and upset. 2, 5 Uncertainty about how and what to share with children can be compounded by the unpredictable disease trajectory of patients with COVID-19. However, even toddlers are perceptive of subtle changes when someone in their family becomes unwell (eg, people crying and whispered conversations). If explanations are absent, children will draw their own conclusions about what is happening and face these challenging situations unsupported.

Research has shown that parents want guidance from health-care professionals about how to talk to children about illness and death. 2, 5 The need for this support is heightened when families are self-isolating together and adults have little time, space, or privacy to prepare how they will share the news with children. Staff face unprecedented clinical demands and emotional pressure, exacerbated by the absence of face-to-face consultations, which deny opportunities to develop relationships with families. However, professionals should play an active role in helping families tackle these seemingly impossible conversations.

A platform of free resources has been developed to support professionals and families in communicating with relatives and children when a patient is seriously ill or has died. The platform contains guides outlining a framework for telephone calls to relatives when a patient has died of COVID-19. Staff are prompted by a specific question to establish if the patient has important relationships with any children. When children are identified, the step-by-step guide provides a rationale for relatives about the importance of talking to children, with suggested phrases to help them approach these life-changing conversations. This content leads into a second infographic and animation, which staff should share with the family to facilitate caregivers' subsequent conversations with children.

COVID-19 presents a bewildering array of challenges for health care, public services, and communities across the world. Empowering adults to communicate with children about illness and death has the potential to mitigate the short-term and long-term psychological effect. The news that children currently face might seem almost unspeakable. But, together, we must find words, and ways, to give voice to their experience and prevent millions of children struggling with their fears and uncertainty alone.

We declare no competing interests. 

Protecting the psychological health of children through effective communication about COVID-19

Communication with children and adolescents about the diagnosis of a life-threatening condition in their parent

Current approaches to helping children cope with a parent's terminal illness

Children's psychological distress following the death of a parent

Communication with children and adolescents about the diagnosis of their own life-threatening condition

Talking with children about death

Adolescent bereavement following the death of a parent: an exploratory study

Talking to children about illness