Innovations in End-of-Life Care
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Silverman PR. Never Too Young to Know: Death in Children's Lives. New York: Oxford University Press, 2000.

Death touches the lives of children regularly, the death of a pet, friend, teacher, parent, sibling. Yet, as a society, we avoid acknowledging this reality. But the fact is that death is always a part of life and frequently affects the lives of children. We also seem to have developed the belief that children will somehow be shielded from the pain associated with loss if we avoid talking with them about death when it does occur. Unfortunately, in response to our discomfort when children do have to endure significant emotional loss and pain, we often leave them alone to manage life's most difficult challenges. For too long, children's grief has been examined and discussed without regard to the way their experience is embedded in their families and the larger social system. Additionally, there is a frequent assumption that the death of someone as important as a parent is likely to derail a child and result in the development of psychopathology.

In Never Too Young to Know, Phyllis Silverman challenges these widely embraced beliefs. She provides a model for understanding grief in children that is embedded in the developmental and social context in which all of life's experiences exist. She deals with the complexities of grief in a very clear, logical way, and lays out the difficult feelings and challenges associated with adjustment to loss as they are experienced developmentally and within a family context. The overall emphasis of the book is on coping and adaptation. She stresses how important it is for children to be given accurate information geared toward their developmental level, and the capacity children have to adapt to crisis and loss when they are given the appropriate support, particularly from a parenting figure, but from the larger social system as well. So, while the death of a loved one does become a part of the fabric of a child's life and who that young person is, it does not typically result in abnormal development.

Never To Young to Know is well organized and easy to read. The book is divided into three main sections. Part I provides a theoretical basis for understanding grief in children. In this section, Phyllis Silverman examines historical factors that have molded the ways in which we view death, as medical technology has resulted in keeping people alive much longer, successfully treating formerly life threatening illnesses, and moving death out of the home and everyday life. She also describes the ways that, in keeping with other social changes, our theoretical and social understanding of grief has evolved. For much of the last century, models for understanding grief were heavily influenced by Freud, who stated that the work of grief is geared toward emotionally detaching from the deceased so that the bereaved can reinvest their energy in new relationships. The influence of these beliefs is still quite prevalent today. It is common to hear people talk about "letting go," "moving on," or "obtaining closure." Drawing from her research with the bereaved, the author offers a new paradigm for understanding the grief process. This paradigm focuses on how we make meaning of our world, the ways in which we hold on to our connections to deceased loved ones, and the dynamic nature of these internally held relationships.

Silverman also stresses the importance of looking at children's experience and expression through a developmental lens. She provides a solid overview of child development, laying the groundwork for understanding the grief process, as well as presenting theory on family systems and family dynamics, since children's worlds are defined and molded by the families and larger social context in which they live.

Part II brings the new paradigm to life through the voices of bereaved children and parents. Vignettes and quotes from many bereaved children and adults who care for them are heavily interspersed throughout the chapters and succeed in painting a clear picture of the grief process and its role in the lives of children and families. In different chapters Silverman addresses the effect of different types of losses and the various ways in which children cope. While there are many shared elements to grief reactions anytime we lose a person we love, there are also differences in responses to grief—from person to person, family to family, as well as elements that are specific to the nature of the loss. When a child looses a parent, the realities of the world the child lives in are altered drastically, as the entire family will shift to accommodate to this loss. Usually, the remaining parent will seem different, as that parent struggles with his or her own grief. Questions and fears about who will fill the roles of the person who is gone are paramount. When a sibling dies, the loss is yet again distinct. The child loses a particular relationship, possibly a playmate or competitor, someone the child may have cared for, a role model, a friend. Also, often overlooked but given full attention here, is the experience for children of having a friend die. With each of these types of losses, Silverman describes the ways in which children attempt to cope and adapt to the loss and their changed world. She describes the behavioral expressions of many of the difficult feelings children struggle with, again drawing heavily from the voices of children themselves and from the parents who observe and interact with them. Through their stories, the reader gains insight into the meaning of various behaviors, such as a child who is lashing out in anger, and an understanding of helpful ways to respond. In keeping with the important role the connections with the deceased play in this paradigm of the grief process, with each type of loss Silverman offers descriptions from children and adolescents of the positive roles their ongoing internal relationships play in their development over time.

While there is information throughout the book on responding to children's grief and helping them develop important tools for coping with the difficulties life hands them, Part III has helping as its focus. Silverman describes informal helping, which comes from family and friends, teachers, religious communities, and other elements of the social world of the child and his or her family, including practical and emotional support. She also describes formal helping, such as counseling, support groups, and mutual help groups, emphasizing the importance of the bereaved paying attention to whether support that is being offered truly feels helpful or not, and to trust their sense of what they need.

Several messages in this book are very clear. Grief is a normal, albeit difficult and challenging, part of life. And as a normal part of life it does not usually result in the development of pathology, especially when a child is supported in dealing with the difficult feelings associated with loss. The children in this book tell us so clearly how much they need information and need to be listened to in order to cope with all the challenges of the grief process as they continuously rework their experience as they grow. Finally, we should not wait until a child has experienced a devastating loss to begin to teach them about death. We need to begin addressing death as a normal and guaranteed part of the human condition, so that children and adults alike have experience and skills in coping with life when they are posed with the enormous challenge of adapting to the death of a loved one.

Carol Wogrin, RN, PsyD

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