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Many children's story books deal with death as a central theme.
•
All of the books analyzed contain elements that facilitate the understanding of death.
•
Not all of the books analyzed reflect the grieving process.
•
The word “grieving” is not mentioned in any of the books analyzed.
•
Story books can be used to facilitate a dialogue about death.
Abstract
Background
Grieving is an adaptive process in the face of the death of somebody close. Children grieve the loss of a family member or friend and need support from their caregivers and the professionals who care for them during this process. Failure to talk to children about the death of a family member or friend can lead to prolonged grief. Children's story books are one of the resources available for providing this type of support.
Objective
To provide the nursing professional with information on story books aimed at children from 7 to 11 years of age as a tool to help them understand and cope with grief.
Design
A systematic integrative review was conducted.
Methods
A search was performed in the ISBN database of the Ministry of Culture and the University Libraries Network. Data extraction was performed by two coders using a protocol registered in PROSPERO.
Results
Fifty-six books met the inclusion criteria. Twenty-five percent of the deceased characters were grandparents and 30.4% died due to illness. The most frequent emotion was sadness, (43.3%) and the most repeated coping strategy was remembering the deceased person, (28.7%). The grieving process was depicted in 32.1% of the selected stories.
Conclusion
The children's books reviewed support understanding and coping with grief. However, some limitations were detected, and therefore it is advisable to accompany the child while reading these books to discuss aspects that have not been addressed.
Nursing professionals commonly deal with people who are grieving. Often, children are those affected by loss. Therefore, nurses should have a good understanding of the concept and characteristics of grief and be knowledgeable of the resources available to provide care (
The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research.
Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division.2007; 36: 253-259
) which may be associated with physical and psychological health problems, such as aggressive behavior, sleeping and eating problems, regression, somatization, and headaches, among others (
). Consequently, these children are likely to use health services more often and make specific demands on pediatric nurses, who are expected to address the needs of the child-family unit as part of their professional duties. In the event of the death of a family member, surviving adults can become an important support for the grieving child, although they need professional guidance. Nursing care can therefore be channeled towards recommending accessible resources, such as children's stories, so that families can help their grieving children understand and express what is happening to them.
Four characteristics of death are described, which are gradually grasped throughout childhood: universality (we are all going to die), irreversibility (no one who dies comes back to life), non-functionality (vital functions and psychological processes are lost) and causality (death has a physical cause) (
). Although there is no absolute agreement in the scientific literature, the idea of irreversibility is the first to develop (5–6 years), followed by universality and non-functionality (6–7 years), whereas causality is reported to develop later (between 8 and 10 years) (
). Regarding possible causes of death, when children aged 9 to 11 are asked about death, they most often cite acts of violence (war, terrorism) and accidents, and, less frequently, illness and aging (
) and leads to the experience of grief. Grief is an adaptive and non-pathological life process as long as people have the cognitive, linguistic and socio-emotional strategies and skills to cope with it (i.e., coping resources) (
The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research.
Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division.2007; 36: 253-259
The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research.
Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division.2007; 36: 253-259
), especially if the loss experienced leaves the person in a situation of high vulnerability. This could be the case of children who experience the death of someone very close to them, mainly their father, mother and/or siblings (
The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research.
Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division.2007; 36: 253-259
). This support aims to help the person to identify, understand and express their emotions as well as to normalize them. It attempts to offer a supportive environment in which they know that all their emotions will be accepted but, at the same time, they must be helped to channel the behavioral consequences if they harm themselves or others. In addition, resolving grief involves keeping the memory of the deceased person because grieving is not about forgetting, rather, on the contrary, about remembering that person, but in a manner that does not prevent us from reorganizing our life in a healthy way after the loss (
A series of guidelines have been recommended by experts for application in cases of child bereavement. One recommendation is to allow the children to attend and actively participate in the mourning rituals, if they wish, and to inform them beforehand about what it consists of, what they will see or hear, what their meaning is (
Because I’m also part of the family. Children’s participation in rituals after the loss of a parent or sibling: A qualitative study from the children’s perspective.
Omega-Journal of Death and Dying.2016; 73: 141-158
). In these conversations, it is necessary to explain the nature of death, to pronounce the word “death” without using euphemisms, to explain what it means when the family member or friend's body disappears forever and to tell them the truth about what happened immediately. If this communication does not take place, children will experience more problems regarding asking questions and solving their doubts as well as expressing their feelings (
Introducing a child-friendly mediating object, such as story books, can help children acquire a more accurate concept of death and make them more aware of the emotions linked to grieving because children tend to identify with the characters and the situations experienced (
). An essential function of these stories is that children can identify with the characters and the situations they reflect, which serves as a trigger to start a conversation (
). Thus, books dedicated to death and bereavement can be a tool to offer to family members as part of nursing care.
However, before recommending this tool it is important to analyze it. Therefore, the main objective of this review was to answer the following question: Do death-themed children's storybooks published in Spanish for children ages 7 to 11 feature content that is likely to facilitate a dialogue on the characteristics of death and grief?
The requirements of the books included in the review were as follows: the books should have grieving protagonists with different characteristics in terms of gender (some with a male protagonist, others with a female protagonist) and skin color, to facilitate emotional identification. It would also be desirable to include people with different abilities. In addition, they should include the most frequent cases of death in children's lives: grandparents, father, mother, sibling, and some stories should also include the death of a friend, classmate, or pet.
Ideally, each story should also cover at least the following aspects:
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Include the conceptual characteristics of death that are being acquired in the selected age range (7 to 11 years).
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Explicitly discuss the existence of grief as a long process, as well as the variety of emotions and behaviors that accompany it, so that children can recognize these as an integral and normative part of the grieving process.
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Refer to farewell rituals, such as burial or funeral, by depicting the attendance of children.
Although there are other published studies analyzing death in children's story books (
), to our knowledge, there is no systematic integrative review that analyzes death and grief in books aimed at children between 7 and 11 years old published in Spanish in the last thirty years.
Method
Design
A systematic integrative review is an ideal review method that consolidates the knowledge obtained from the literature, in order to draw a conclusion on a given topic (
Between November and December 2021, a search was conducted for children's story books in the library of the Faculty of Nursing of the University of Cantabria, the ISBN database of the Ministry of Culture and Sport and the University Libraries Network (REBIUN). Also, the PubMed, Dialnet, Scopus, Web of Science and Cuiden plus databases were consulted.
The MeSH terms “Death”, “Grief”, “Bereavement”, “Child”, “Nursing” and “Juvenile Literature” were used, combined with the Boolean operator “AND”.
Inclusion and exclusion criteria
The inclusion criteria were as follows: a/ books with a central theme of death, b/ aimed at children between 7 and 11 years of age, c/ paper format, d/ published in Spanish and e/ first edition published between 1991 and 2021.
Data extraction
To carry out the review, a protocol was created that included a timeline, the coding sheet and a coding manual, which allowed thirty-three variables to be recorded, grouped into eight categories, including: the characteristics of the main character and the four aspects of the concept of death. The protocol was registered in PROSPERO (International Prospective Register of Systematic Reviews) under number CRD4202232327477.
Two coders independently coded the books. Once coding was completed, inter-coder agreement was estimated; Cohen's Kappa coefficient was used for categorical variables and the Spearman-Brown correlation coefficient was used for quantitative variables. Disagreements were resolved by discussion among coders and, when necessary, the criterion of a third reviewer was used.
Results
A total of 56 books were included in this review (Table 1). The PRISMA flowchart (
After coding, intercoder agreement was 0.90 (Cohen's mean Kappa was κ = 0.86 and the mean Spearman-Brown correlation was r = 0.93).
Characteristics of the books included
Of the selected books, 64.3% (n = 36) were written in the third person as opposed to 35.7% (n = 20) written in the first person. Spanish authors wrote 51.8% (n = 29) of the books (Table 1), 3.6% (n = 2) included a glossary of words and 16.1% (n = 9) provided support material to help parents or caregivers talk with children or provide information about how children experience death and bereavement (Table 2).
Table 2Books with support materials for parents.
Story No.
Spanish title
Synopsis
Support materials included with the book
3
Así era mi abuelito
This story is about the memory that the main character has of his grandfather. Before he died, he made him a cake and gave him a recipe book.
A parent's guide to dealing with the subject of death with children
7
Caramelos masticables
The father of the girl who is the main character in this story tells her that her grandmother is now a star, and she hopes to see her every night.
Activities for remembrance
13
Delfín, una historia de principio a fin
Through the dolphin as the main character, this story tries to explain the difficulties of life and suicide.
Guide to explain suicide to children and key ideas for reading and working with the story.
19
El jardín de mi abuelo
Through nature, the grandfather tries to explain to the main character what the stages of life mean, including death.
Key ideas for reading and working with the story
20
El lenguaje de los arboles
The main character's grandfather teaches him to listen to the sounds of nature, but he doesn't understand it until his grandfather is gone.
A guide for dealing with the subject of death with children
25
Encender la luz
Naiara doesn't understand why her mother's father is no longer around, her mother explains that her grandfather now lives in a star.
A guide for dealing with the subject of death with children
41
Mi amigo el sauce
The squirrel featured in this story learns to understand death through illness as he cares for his friend.
A guide for parents to discuss death with their children and exercises for children
48
Paz. Papá se fue sin avisar
Through her happiest memories with her father, the main character tries to assimilate the sudden loss of her father.
Information for children on What happens when you die, a guide to addressing the subject of death with children and recommendations for reading the story.
55
Un pellizco en la barriga
The main character shows different emotions at the loss of a family member. What no one knows is that she keeps a secret.
Information on how children experience death and grief and key ideas for reading and working with stories
The main character included people, animals, or elements of nature such as a snowflake, although most of the characters were people (66.1%). The most frequent profile was a girl (41.1%), who was white (92.3%) and with no disability (100%) (Table 3).
Animals were the main character in 23.2% of the story books. They were usually animals living in the forest, such as squirrels, bears, raccoons, foxes, although there are also stories about lambs, pigs, fish, and ducks. In these stories, the animals are humanized (they live in houses, wear clothes, talk to their peers, express emotions) and are not shown as human.
Approach to death and grief
Grandparents were the most frequently deceased characters depicted in 37.5% (n = 21) of the books, followed by parents, at 25% (n = 14) or a friend, as shown in 8.9% (n = 5) of the books. The main character dies on four occasions (Table 4).
Most often there was no mention of who communicates the death to the main character, but when this was depicted it was usually the mother 19.6% (n = 11). Also, no mention was usually made of where the death occurs, however when it was shown it was either in nature (21.4%), at the hospital (16.1%) or at home (14.3%). Funeral rituals were also infrequent.
The cause of death was not usually mentioned; when cited, the most frequent cause was illness (32.1%), followed by old age (10.7%). Other reasons, such as accidents or suicide, were found in 8.9% and 1.8% of the books, respectively.
Regarding the characteristics of death (universality, irreversibility, non-functioning, and causality), all four are projected in four books, although most frequently two of these characteristics are shown, with irreversibility being the most present characteristic (44.7%), followed by causality (29.1%).
The word “grief” fails to appear in 100% of the story books (n = 56). Although implicitly, the grieving process is shown in 33.9% (n = 19). Of the stories that show grieving, in 63.2% (n = 12) it is represented as a long process versus 36.8 (n = 7) where it appears as a short process.
Emotions and coping
The impact of death is shown for both the main character and other characters in 66.1% of the books (n = 37) and only concerning the main character in 12.5% (n = 5).
Emotions are expressed both with words and drawings in 87.5% of the books (n = 49), only with words in 5.4% (n = 3) and not shown in 7.1% (n = 4). The most depicted emotion, shown both by the main character and by the other characters, was sadness, in 47.4% (n = 45) of the books, and a manifestation of it, crying, in 24.2% (n = 23).
Regarding the most used coping strategies, these were remembering the deceased, 28.7% (n = 39), sharing memories, 17% (n = 23) and receiving support, 18.4% (n = 25). Conversely, in 3.7% of the books (n = 5) no coping strategy was shown (Table 5).
Table 5Strategies for coping with death shown in the stories.
Story No
Spanish title
Coping strategya
1
Abuela de arriba, abuela de abajo
1,3
2
Al otro lado
0
3
Así era mi abuelito
1
4
¡Buenas noches, abuelo!
1,2,3
5
Camila y el abuelo pastelero
1,2,4
6
Camila, ¡regresa, abuelito!
0
7
Caramelos masticables
1,2.3,5,7
8
Casi, casi
7
9
¿Cómo es posible? La historia de Elvis
2,3,5
10
Copito de nieve
0
11
Cuando la muerte vino a nuestra casa
3,5,7
12
Cuerpo de nube
1
13
Delfín, una historia de principio a fin
1,2,5
14
¿Dónde está el abuelo?
3.5
15
El abuelo de Tom ha muerto
1,2,3,5
16
El ángel del abuelo
0
17
El árbol de los recuerdos
1,2,3,7
18
El camaleón malcarado
1
19
El jardín de mi abuelo
1,4,5
20
El lenguaje de los arboles
1,2,3,7
21
El niño de las estrellas
1,2,4,5,7
22
El pájaro muerto
1,5
23
El pato y la muerte
4
24
En todas partes y en cualquier lugar
1,2,3,4,7
25
Encender la luz
1,2
26
¡Gracias, vida!
3,4
27
Háblame de ella
1,2,3,7
28
Huesos
1,2,3,7
29
Iliana, la niña que escuchaba al viento
1,2
30
Inés Azul
0
31
Jack y la muerte
5
32
Julia tiene una estrella
1
33
La cabina de teléfono en el jardín del señor Hirota
12
34
La caricia de la mariposa
1
35
La estrella de Lea
1
36
La isla del abuelo
1,5
37
La niña y el árbol de las grajillas
1,2,3
38
¡Mamá!
1,2,3,5,6,7
39
Más allá del gran río
1,2,3,5,7
40
Mi abuelita ya no está
1
41
Mi amigo el sauce
1,3,6
42
Nana vieja
5,6
43
No es fácil, pequeña ardilla
1,2,3
44
No puedo dormir
3
45
Osito y su abuelo
3
46
Para siempre
1,2,3,7
47
Para siempre
1,4
48
Paz. Papá se fue sin avisar
1,2,3
49
¿Por qué papá ahora es una estrella?
1
50
¿Qué viene después del mil?
1.3
51
Soy la muerte
8
52
Te encuentro en el arcoíris
1
53
Tim dice adiós a su abuelo
1,3
54
Tres pececitos
3,7
55
Un pellizco en la barriga
1,2,5,7
56
Yo quiero saber de verdad qué es la muerte!
1,2,4,5
a1: Remembrance, 2: Sharing memories, 3: Receiving support from others, 4: Talking about death, 5: Saying goodbye, 6: Caring for the dying person, 7. Offering support to others, 8 Other.
Storytelling for bereaved children, a form of bibliotherapy, can provide an opportunity to talk about death and grief, answer children's questions, clarify their doubts, and normalize their emotions. Reading stories to children can help them to express and release their emotions in a safe environment (
). In this review, we analyzed 56 children's books for children between 7 and 11 years of age, which, overall, deserve a positive evaluation, although they have some limitations.
To favor the projection of their feelings and emotions, children need to be able to identify with the story's main character, therefore, it is important to include characters of different sexes and with different characteristics. However, we have found that none of the books had characters with some type of disability and all the characters tended to be white, which may constitute a limitation as some children may fail to identify with them. This is in line with findings by
who mention the lack of ethnic and cultural diversity in these stories.
Regarding the characteristics of the deceased, most of the deceased were grandparents, followed by fathers, mothers and siblings, which seems understandable and realistic given the higher probability of death of grandparents (
). Only two of the books dealt with the death of a friend, and these characters were animals instead of people.
Regarding the emotions shown, the most frequently depicted emotion is sadness (and crying as a reflection of it). However, the wealth of emotions that is usually generated by grief does not appear (
) are barely represented. In the media, at least prior to the COVID19 pandemic, accidents are mentioned more often as a cause of death, compared to disease. This is probably why accidents are the most cited element by children, however they are hardly represented in the stories. It is known that children are most exposed to the death of their grandparents, and grandparents generally die from illness. However, road traffic accidents are the most frequent cause of death in people between five and 29 years of age (
) therefore, this can affect siblings and friends of children aged seven to 11 years, as well as young parents. Consequently, death-themed storybooks have to be adjusted to these experiences of bereaved children.
A major limitation is that not all books use the word “death”. Rather, they use circumlocutions or euphemisms such as “he is gone”, “now lives in a star” or similar. Also, regarding the characteristics of death, universality and non-functionality are shown in a minimal percentage of the stories. It would be key for these characteristics to appear, since children understand these concepts between the age of seven and ten (
The death of a family member inevitably implies a grieving process. For this reason, children's books that deal with death should also help the child understand this stage. None of the books analyzed mention the word grief, and when this process is depicted, it is generally shown as a short process that is resolved almost immediately after the death. However, it is known that grief is a process, not a state, and therefore it is long (
). Nevertheless, grief is addressed, as most of the stories include coping strategies. Overall, the most important ones are mentioned in the stories, among these, perhaps the most counterintuitive is that of remembering the deceased, since, as we have indicated, coping with grief in a healthy manner is not about forgetting but about finding a lasting and healthy way to feel connected with the deceased person (
The nursing professional is in constant contact with families affected by death. Therefore, in addition to performing active listening and showing support, nurses can carry out two tasks for which we believe this study is useful: a) integrating children's story books to work on death and grief; and b) recommending children's story books to families as part of nursing interventions in children's bereavement.
Because of its symbolic power, children's literature serves as a tool to promote dialogue with children about death and to help them understand the grieving process, since it contains elements that facilitate understanding and coping. However, we have detected highlights, but also some limitations, and therefore it is important to provide recommendations to parents and/or caregivers so that children's literature can be used as a tool to provide more comprehensive support.
Practice implications
This study can serve as a reference for health professionals to integrate children's story books in their work as an intervention to address death and bereavement. In addition, it can guide the nursing staff in recommending death-focused books suited to the needs of each user. This information can be further expanded with recommendations on how to read these stories (
Supporting children’s social and emotional growth through developmental bibliotherapy.
in: Kerry-Moran J.A. Aerila K.J. Story in Children’s lives: Contributions of the narrative mode to early childhood development, literacy, and learning. Vol. 16. Springer,
2019: 299-314
). Such recommendations include reading the story carefully before reading it to the child so that the adult can reflect on the comments and possible questions to be asked during and after reading; reading in a quiet environment, without interruptions; and reading without rushing, leaving time for a long conversation so that the children can ask questions and express their feelings while the story is being read.
Finally, this study can also be useful for other professionals who are in close contact with children, such as kindergarten and primary education teachers since children spend most of their time in the school environment.
Contributions of this study
Nursing professionals are in contact with children and families and can provide tools to help with the grieving process. This study lists and analyzes the approach to death and grief in 56 children's story books published in Spanish with a central theme of death that can facilitate understanding and coping with grief in children from 7 to 11 years of age.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author contributions
Conceptualization; M-C M., M A, S-G T, A-S M and O-M C.
Data curation; M-C M and S-G T.
Formal analysis; M-C M. and O-M C.
Methodology; M A, A-S M and O-M C.
Project administration; O-M C.
Supervision; M A and O-M C.
Validation; S-G T and A-S M.
Visualization; M-C M., M A, S-G T, A-S M and O-M C.
Writing - original draft; M-C M. and O-M C.
Writing - review & editing: M-C M., M A, S-G T, A-S M and O-M C.
Declaration of Competing Interest
The authors have no conflicts of interest to disclose.
Acknowledgments
We would like to thank Diego García-Valtuille Pérez and Álvar Tapia Ruiz for their help in the search for books.
The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research.
Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division.2007; 36: 253-259
Because I’m also part of the family. Children’s participation in rituals after the loss of a parent or sibling: A qualitative study from the children’s perspective.
Omega-Journal of Death and Dying.2016; 73: 141-158
Supporting children’s social and emotional growth through developmental bibliotherapy.
in: Kerry-Moran J.A. Aerila K.J. Story in Children’s lives: Contributions of the narrative mode to early childhood development, literacy, and learning. Vol. 16. Springer,
2019: 299-314
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