This article deals with the challenges faced by students who are coping with the changes brought about by
Living with a loved one with terminal illness
Losing a loved one due to terminal illness
Content
A person's understanding of death varies with age and experience
"Death" is a concept that is not easy to grasp. It is not something that you can easily point out to a child like 'A is for Apple and B is for Boy'. It takes many years before a human being is mature and experienced enough to understand the concept and implications of death.
To assess a child's understanding of death, researchers have defined death by breaking it down into several components:
Universality: all living things must eventually die
Irreversibility: someone who dies is not able to come back to life again
Non-functionality: a dead person can no longer do things that a living person can
Causality: there is a biological cause for the death
In breaking a news of a death (or impending death) to a child, it is important to find out how much they understand about death. Reducing the concept of death into its components can help provide a useful framework when explaining death to a child and identifying any misconceptions they may have about death.
The understanding of death of school-goers varies depending on their age:
Pre-schoolers (3-6 years old)
Universality: may associate death with old people or very sick individuals; may not understand that death can also happen to healthy people
Irreversibility: may not understand that death is final, may perceive death as "sleeping" and a temporary separation
Non-functionality: may believe that a dead person can continue to move and function
Causality: may explain the cause of death through 'magical thinking' or as a form of punishment from something they have done as pre-schoolers are still relatively egocentric in their thought processes (and therefore may feel guilty as a result of this)
Primary Schoolers (7-12 years old)
Universality: lower primary schoolers may not be aware that death can happen for young and healthy people; upper primary schoolers may understand that death can happen to anyone
Irreversibility: may understand that death is permanent
Non-functionality: understand that a dead person is non-functional but may worry that dead people can still feel pain (and therefore worry about the deceased experiencing pain and discomfort during cremation or burial)
Causality: as they gain a better understanding of science, they are better able to provide realistic causes for death
Secondary Schoolers and above (≥ 13 years old)
Universality: understand that death applies to everyone
Irreversibility: understand that death is final
Non-functionality: understand that a dead person is non-functional
Causality: understand that there are a variety of causes for death
Despite having a relatively "adult understanding" of death, they often do not have the ability to cope with death like adults can. They may also not be able to empathise with another person who has just lost a loved one.
Grief manifests in many different ways
Due to their inability to comprehend and cope with the onslaught of emotions, grief can manifest in a multitude of ways in school-goers. This will be a non-exhaustive list on how school-going children manifest grief differently from adults and in ways that may seem puzzling.
Physical Manifestations
Pre-schoolers may exhibit regressive behaviours such as thumb sucking, bed-wetting, and baby talk. Other physical symptoms of grief include changes in appetite and sleep, difficulty breathing, chest discomfort and abdominal pain. If symptoms are persistent or worsening, do consult a medical professional on whether there is a serious underlying cause of the symptoms that is unrelated to grief.
Anger outbursts and misbehaviour
Adolescents may become rebellious and aggressive as a means of coping with their emotions. Complicated bereavement in adolescents may be characterised by school refusal, drug or alcohol usage, shoplifting, shifting to a more delinquent group of friends, or precocious sexual behaviour.
Manifesting grief-related behaviour on an intermittent basis
Children tend to only be able to sustain strong emotions for brief periods of time. They may alternate between approaching and shunning their emotions so as to prevent feeling overwhelmed. This may incorrectly lead to the assumption that they are coping well during periods when they are avoiding their problems.
While adults are able to sustain continuous periods of intense grieving, children tend to exhibit grief on an intermittent basis over a longer period of time.
The bereavement process tends to be stretched out over many years as their reaction to the loss of a loved one is revived, revisited and reviewed as they mature (e.g. passing an exam and graduating, entering a new school, applying for their first internship). Hence, it is important to re-address these issues at different developmental and chronological milestones.
Self-blame and guilt
Young children may believe that they are the cause of their loved ones death because of their bad behaviour or something they did or didn't do. This is in contrast to adults who tend to feel guilty for not having spent enough time with their loved one before they passed on.
Older children may feel guilty for prioritising school over looking after their loved one or for being angry and frustrated at their loved one before they passed on.
Negative self-assessment
Following death, school-goers may become more insecure and have low self-esteem. For young children, this may be because they interpret the death as an act of desertion rather than due to biological causes. For older children, they may view themselves as helpless and vulnerable.
What are some of the challenges faced when grieving in the school setting?
This is usually their first encounter with death. They will be forced to confront many new situations and emotions for the first time. They may find themselves stumbling in the dark and may often think to themselves "no one understands".
Grappling with the finality of death
All previous ideas about final goodbyes were likely from television shows and story books. This will often be the first time a school-goer is experiencing the finality of death in real life and experiencing the emotional toll from realising that they will never see the person again.
Feeling different from everyone else and struggling to determine what is normal
School-goers may not have previously observed another person mourning the loss of a loved one. Hence, they have no model to follow when trying to figure out what a normal reaction is and how they should behave. They may not know how long they should feel sad for. They may even feel guilty or weird that they don't feel anything at all at times and wonder if they are 'normal'.
They may observe all their friends around them going about with their lives and wonder why they feel so disconnected and why their lives are so vastly different.
They may compare themselves to others and feel bitter that other people have families that are intact but they do not. They may feel frustrated that they have additional roles and responsibilities (e.g. caregiving, holding extra jobs, household chores) that their friends do not have to bother with.
Friends don't seem to understand or care
At the school-going age, many students would not have experienced death of a loved one. They may not know how to empathise or provide support. They may also react in ways that cause hurt to the person experiencing loss.
If a student has just lost or is about to lose a loved one, there may be certain group activities that he or she may not want to participate in. This may be because they are dealing with personal struggles or that they feel strange hanging out with people that are happy when they don't feel happy themselves. They may find very little meaning in spending time playing games at an arcade or watching a movie with friends when they have duties to attend to at home.
They may also not be allowed to participate in certain activities. This may be due to financial constraints (due to loss of a source of income in the family) or it may be due to superstitious beliefs (e.g. some cultures may not allow you to visit other people's homes for a period of time following a family member's death).
It is not uncommon that friends instinctively prioritise their own happiness and pursuits over providing a safe space for someone to grieve due to their lack of understanding and experience. Some may even feel bitter if their peer is receiving special attention from the school because they have lost a loved one, especially if they are not outwardly exhibiting signs of grief.
Due to the paramount importance placed on social acceptance by adolescents, this disconnect from their peers can make a grieving student feel very alone.
Lost opportunities and falling behind are a big deal
Many things happen only once a year in schools (e.g. final year exams, SYFs, sport competitions, overseas trips). When a school-goer misses out on one of these, it feels like a very big deal because all their peers appear to be progressing while they have not.
(This is in contrast to the adult working world where everyone's lives are so vastly different and complex that when you miss out on an opportunity, the difference compared to peers may seem less pronounced. Also, an adult is more used to failure and disappointment e.g. it is more commonplace to get rejected in job applications, not get a promotion.)
Missing out on lessons and falling behind from looking after a loved one with terminal illness or grieving from a death could result in poorer academic performance. Inability to concentrate as a result from grief can also contribute to this. Failing the end of year exams may mean not progressing to the next year or school or not getting into a school of their choice - this can place an immense amount of stress on a student.
Not being selected to represent their CCA for milestone events can also be a huge disappointment to a student.
Taking up new roles to fulfil (that may sometimes feel too early for their age compared to their peers)
Parental death results in destabilisation of the family structure. A student in this situation may find themselves taking up new responsibilities such as caring for their remaining parent or looking out for their other sibling. They may take up household chores such as cooking and cleaning as they feel compelled to take on the roles left behind by the deceased.
Some may experience financial constraints and have to consider taking up part-time jobs or saving money by not going out with friends and eating less.
What can you do to help?
Explain death clearly and talk about death openly
To a young school-goer, use concrete words such as 'die' instead of vague terms such as 'gone to a better place'. This will help decrease their confusion and improve their understanding of death.
To all students experiencing loss, talk to them openly about death to let them know that it is safe for them to talk about it and encourage them to ask questions. Children tend to model the way adults behave around them - if adults avoid talking about the death, the child may also do the same and this may interfere with their healing process.
Involve them in the decision-making process of the care of their loved one as much as is appropriate or keep them informed of the decisions being made e.g. explain what will happen during the funeral beforehand.
Communicate with the school about the situation
Inform the form teacher/CCA teacher-in-charge/lecturer about the situation at home. This is so that they look out for the student in terms of behaviour and academic performance. They may be able to help with mediating the behaviour of their classmates and explaining what death is and how to empathise with a grieving student - however, this is entirely to up their own discretion.
Check the school's attendance and exam policy in advance
How many days of compassionate leave is a student entitled to?
What documents do you have to submit in order to obtain approval for leave of absence from school?
What is the protocol in place to re-sit for examinations in the event that they are missed?
If there are group participation and presentations that are missed, how will they adjust the measurement of the student's performance?
If a longer period of leave is deemed required, speak to the principal or dean who will assess the leave of absence on a case-by-case basis e.g. taking a gap semester.
Utilise school counselling services
Counselling provides a safe environment for students to share their emotions and process their grief. Students may not feel comfortable telling their peers about their problems for many reasons.
According to the Ministry of Education's website, there are three levels of counselling and student welfare support in schools
1. Support by teachers are the first level of support
2. Referrals to counsellors or student welfare officers are made for students who need specialised attention
School counsellors who are professional counsellors with either a Diploma, Bachelor or Master Degree in Counselling
Teacher-counsellors are teachers that are trained in counselling skills including areas such as suicide intervention, grief and loss counselling, and psychological first aid
Student welfare officers is a staff trained to mitigate the risk factors that may affect students' attendance and reintegrate these students back to school
3. Referrals to specialists or community agencies are made for students for require more intensive intervention
If you are a friend of a grieving student, here are some ways you can provide support:
Offer to share your school notes with your friend
Check what social activities your friend is comfortable with (given emotional and financial constraints and family commitments) and actively offer them the option to be involved in social activities together. It may not have to be something action-packed or a heart-to-heart talk; it can simply be sitting within the same space to process individual thoughts silently
Be patient when they are unexpectedly irritable or are unable to participate as much in group projects
Understand that grief waxes and wanes and has no fixed timeline or expiry date
Take note of significant anniversaries (e.g. birthdays, death dates) and events (e.g. graduation, meet-the-parent sessions, weddings) and offer your support - it can be as simple as dropping a text to say that you are here for them if they need you to be around
Offer to source for professional help if your friend shows signs of self-harming thoughts or behaviour, intense emotions that compromise health, loss of interest in activities, and social withdrawal (list of helplines available here)
Conclusion
The grieving process of young people differs from adults due to developmental differences and lack of life experiences. It will be their first time dealing with many of these issues and their peers may not be able to understand their struggles or provide adequate support. Hence, whenever you are aware of a young person who is grieving and handling school at the same time, do reach out to offer your support!
References
Singapore Hospice Council. Caring for yourself and others after a death. https://singaporehospice.org.sg/site2019/wp-content/uploads/Caringforyourselfandothers-web.pdf
Speece MW (1995). Children's Concepts of Death. Michigan Family Review. https://quod.lib.umich.edu/m/mfr/4919087.0001.107/--children-s-concepts-of-death?rgn=main;view=fulltext
Osterweis M, Solomon F, Green M (1984). Bereavement: Reactions, Consequences, and Care. https://www.ncbi.nlm.nih.gov/books/NBK217849/
Robin L, Omar HA (2014). Adolescent Bereavement. https://uknowledge.uky.edu/cgi/viewcontent.cgi?article=1120&context=pediatrics_facpub&httpsredir=1&referer=
PDQ Supportive and Palliative Care Editorial Board. Grief, Bereavement, and Coping With Loss (PDQ®): Health Professional Version. 2020 Dec 3. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK66052/
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