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Grief in children's story books. A systematic integrative review

Open AccessPublished:January 02, 2023DOI:https://doi.org/10.1016/j.pedn.2022.12.012

      Highlights

      • 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.

      Keywords

      Introduction

      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 (
      • Nielson D.
      Discussing death with pediatric patients: Implications for nurses.
      ;
      • Thirsk L.M.
      • Moules N.J.
      “I can just be me”: Advanced practice nursing with families experiencing grief.
      ).
      Grieving is a normal process of sorrow or woe in the face of loss, which is influenced by culture (
      • Sood A.B.
      • Razdan A.
      • Weller E.B.
      • Weller R.A.
      Children’s reactions to parental and sibling death.
      ) and always requires adaptation to the new situation (
      • Alvis L.
      • Zhang N.
      • Sandler I.N.
      • Kaplow J.B.
      Developmental manifestations of grief in children and adolescents: Caregivers as key grief facilitators.
      ;
      • Currier J.M.
      • Holland J.M.
      • Neimeyer R.A.
      The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research.
      ). It may be reflected through a wide range of emotions (sadness, fear, anxiety, anger, guilt, anguish, envy) (
      • Alvis L.
      • Zhang N.
      • Sandler I.N.
      • Kaplow J.B.
      Developmental manifestations of grief in children and adolescents: Caregivers as key grief facilitators.
      ;
      • Chachar A.S.
      • Younus S.
      • Ali W.
      Developmental understanding of death and grief among children during COVID-19 pandemic: Application of Bronfenbrenner’s bioecological model.
      ;
      • Ferow A.
      Childhood grief and loss.
      ). Among children who have lost a close family member, post-death adjustment can be a complex process (
      • D’Alton S.V.
      • Ridings L.
      • Williams C.
      • Phillips S.
      The bereavement experiences of children following sibling death: An integrative review.
      ) which may be associated with physical and psychological health problems, such as aggressive behavior, sleeping and eating problems, regression, somatization, and headaches, among others (
      • Lytje M.
      • Dyregrov A.
      The price of loss–a literature review of the psychosocial and health consequences of childhood bereavement.
      ;
      • Revet A.
      • Bui E.
      • Benvegnu G.
      • Suc A.
      • Mesquida L.
      • Raynaud J.P.
      Bereavement and reactions of grief among children and adolescents: Present data and perspectives.
      ). 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) (
      • Chachar A.S.
      • Younus S.
      • Ali W.
      Developmental understanding of death and grief among children during COVID-19 pandemic: Application of Bronfenbrenner’s bioecological model.
      ;
      • McGuire S.L.
      • McCarthy L.S.
      • Modrcin M.A.
      • McGuire S.L.
      • McCarthy L.S.
      • Modrcin M.A.
      An ongoing concern: Helping children comprehend death.
      ). 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) (
      • Panagiotaki G.
      • Hopkins M.
      • Nobes G.
      • Ward E.
      • Griffiths D.
      Children’s and adults’ understanding of death: Cognitive, parental, and experiential influences.
      ). A mature understanding of these four characteristics of death is not typically achieved until the age of 10 (
      • Kenyon B.L.
      Current research in Children’s conceptions of death: A critical review.
      ). 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 (
      • Vázquez-Sánchez J.M.
      • Fernández-Alcántara M.
      • García-Caro M.
      • Cabañero-Martínez M.J.
      • Martí-García C.
      • Montoya-Juárez R.
      The concept of death in children aged from 9 to 11 years: Evidence through inductive and deductive analysis of drawings.
      ).
      The death of a family member (father, mother, sibling, grandparent) is not a normative event during childhood, however it is not uncommon (
      • McGuire S.L.
      • McCarthy L.S.
      • Modrcin M.A.
      • McGuire S.L.
      • McCarthy L.S.
      • Modrcin M.A.
      An ongoing concern: Helping children comprehend death.
      ;
      • Revet A.
      • Bui E.
      • Benvegnu G.
      • Suc A.
      • Mesquida L.
      • Raynaud J.P.
      Bereavement and reactions of grief among children and adolescents: Present data and perspectives.
      ) 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) (
      • Alvis L.
      • Zhang N.
      • Sandler I.N.
      • Kaplow J.B.
      Developmental manifestations of grief in children and adolescents: Caregivers as key grief facilitators.
      ;
      • Currier J.M.
      • Holland J.M.
      • Neimeyer R.A.
      The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research.
      ). Nonetheless, children's resilience is not unlimited (
      • Lytje M.
      • Dyregrov A.
      The price of loss–a literature review of the psychosocial and health consequences of childhood bereavement.
      ). Indeed, grieving individuals require proper accompaniment (
      • Currier J.M.
      • Holland J.M.
      • Neimeyer R.A.
      The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research.
      ;
      • Roche R.M.
      • Brooten
      • Youngblut J.A.M.
      Children’s fears 2-13 months after sibling NICU/PICU/emergency department death.
      ), 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 (
      • D’Alton S.V.
      • Ridings L.
      • Williams C.
      • Phillips S.
      The bereavement experiences of children following sibling death: An integrative review.
      ;
      • Roche R.M.
      • Brooten
      • Youngblut J.A.M.
      Children’s fears 2-13 months after sibling NICU/PICU/emergency department death.
      ). Without this accompaniment, the likelihood of complicated grief increases (
      • Currier J.M.
      • Holland J.M.
      • Neimeyer R.A.
      The effectiveness of bereavement interventions with children: A meta-analytic review of controlled outcome research.
      ;
      • Roche R.M.
      • Brooten
      • Youngblut J.A.M.
      Children’s fears 2-13 months after sibling NICU/PICU/emergency department death.
      ). 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 (
      • Worden J.W.
      Grief counseling and grief therapy: A handbook for the mental health practitioner.
      ).
      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 (
      • Søfting G.H.
      • Dyregrov A.
      • Dyregrov K.
      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.
      ). Another is to talk openly to children about death (
      • Arruda-Colli M.N.F.
      • Weaver M.S.
      • Wiener L.
      Communication about dying, death, and bereavement: A systematic review of Children’s literature.
      ) and certainly answer any questions (
      • Nielson D.
      Discussing death with pediatric patients: Implications for nurses.
      ), if possible before the death of any family members (
      • McGuire S.L.
      • McCarthy L.S.
      • Modrcin M.A.
      • McGuire S.L.
      • McCarthy L.S.
      • Modrcin M.A.
      An ongoing concern: Helping children comprehend death.
      ;
      • Revet A.
      • Bui E.
      • Benvegnu G.
      • Suc A.
      • Mesquida L.
      • Raynaud J.P.
      Bereavement and reactions of grief among children and adolescents: Present data and perspectives.
      ), but also as soon as the loss occurs and throughout the entire grieving process (
      • Chachar A.S.
      • Younus S.
      • Ali W.
      Developmental understanding of death and grief among children during COVID-19 pandemic: Application of Bronfenbrenner’s bioecological model.
      ). Children usually receive less information than necessary due to the assumption that they will not understand it (
      • Alvis L.
      • Zhang N.
      • Sandler I.N.
      • Kaplow J.B.
      Developmental manifestations of grief in children and adolescents: Caregivers as key grief facilitators.
      ). 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 (
      • Arruda-Colli M.N.F.
      • Weaver M.S.
      • Wiener L.
      Communication about dying, death, and bereavement: A systematic review of Children’s literature.
      ).
      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 (
      • McGuire S.L.
      • McCarthy L.S.
      • Modrcin M.A.
      • McGuire S.L.
      • McCarthy L.S.
      • Modrcin M.A.
      An ongoing concern: Helping children comprehend death.
      ). Reading stories to children is an opportunity to start a sincere and honest conversation about death and bereavement (
      • Arruda-Colli M.N.F.
      • Weaver M.S.
      • Wiener L.
      Communication about dying, death, and bereavement: A systematic review of Children’s literature.
      ). 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 (
      • McGuire S.L.
      • McCarthy L.S.
      • Modrcin M.A.
      • McGuire S.L.
      • McCarthy L.S.
      • Modrcin M.A.
      An ongoing concern: Helping children comprehend death.
      ). 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:
      • -
        Include the conceptual characteristics of death that are being acquired in the selected age range (7 to 11 years).
      • -
        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.
      • -
        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 (
      • Arruda-Colli M.N.F.
      • Weaver M.S.
      • Wiener L.
      Communication about dying, death, and bereavement: A systematic review of Children’s literature.
      ;
      • Ortego C.
      • Aparicio M.
      • Paz M.
      • Torres B.
      • Sarabia R.
      • Sevilla L.
      • Agudo
      Tales: A tool to address death with children.
      ), 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 (
      • Soares C.B.
      • Hoga L.A.K.
      • Peduzzi M.
      • Sangaleti C.
      • Yonekura T.
      • Silva D.R.D.A.
      Integrative review: Concepts and methods used in nursing.
      ).

      Search strategy

      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 (
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • Boutron I.
      • Hoffmann T.C.
      • Mulrow C.D.
      • Moher D.
      The PRISMA 2020 statement: An updated guideline for reporting systematic reviews.
      ) (Fig. 1) depicts the selection process. Appendix 1 shows the titles of the excluded books and the reasons for their exclusion.
      Table 1Description of the selected books.
      No. of storiesSpanish title/English title*Year of first editionPublisherAuthors/illustratorsCountry of original versionSupport materialCharacteristics of the main characterWho dies?Uses the word deathDepicts grievingAvailable in
      1Abuela de arriba, abuela de abajo/ Nana upstairs & nana downstairs1994El barco de vaporTomie de PaolaUnited States0BoyGrandmother and great grandmother10English / Spanish
      2Al otro lado / To the other side*2016La fragatinaRoberto Parmeggiani/ Anna ForlatiItaly0BoyFather00Spanish / Italian
      3Así era mi abuelito / That's how my grandfather was*2003Tris TrasJoan de Déu Prats/ Gustavo RoldánSpain1BoyGrandfather10Spanish
      4¡Buenas noches, abuelo! / Goodnight, grandpa!*2013LóguezRoser Bausá/Carme PerisSpain0GirlGrandfather00Spanish
      5Camila y el abuelo pastelero / Camila and the baker grandpa*1999AlfaguaraMarisa López/Nivio LópezSpain0GirlGrandmother10Spanish
      6Camila, ¡regresa, abuelito! / Camila, come back, grandpa!*2021Babidi-búRomina Giugno/Rocío KoizumiSpain0GirlGrandfather02Spanish
      7Caramelos masticables / Chewy candies*2021Babidi-búLourdes López/ Zenaida MadridSpain1GirlGrandmother00Spanish
      8Casi, casi / Almost*2015IstardukMaísa Marbán/Pedro José de ArribaSpain0Boy and GirlGrandfather00Spanish
      9¿Cómo es posible? La historia de Elvis / How is it possible? Elvis' story*2005LóguezPeter SchössowGermany0GirlPet10Spanish / German
      10Copito de nieve / Snowflake*2021Mr. momoMaialen Mediavilla/Tamara DuránSpain0SnowflakeFriend00Spanish
      11Cuando la muerte vino a nuestra casa / When death came calling2011LóguezJürg Schubiger/Susanne BernerGermany0GirlBrother10Spanish/ German/ Chinese / French
      12Cuerpo de nube / Little cloud lamb2010Cuento de LuzAna de Eulate/Mónica CarreteroSpain0LambMain character00English / Spanish
      13Delfín, una historia de principio a fin / Dolphin, a story from start to finsh*2021Babidi-búAlma Serra/Blanca GalvánSpain1DolphinMain character13Spanish
      14¿Dónde está el abuelo? / Where's grandpa?*2001TricicloMar Cortina/Amparo PegueroSpain0GirlGrandfather10Spanish
      15El abuelo de Tom ha muerto / Tom's grandad has died*2000CombelColette Hellings/ Marie-Aline BawinFrance0SquirrelGrandfather13Spanish / French
      16El ángel del abuelo / Grandpa's angel2001LóguezJutta BauerGermany0BoyGrandfather00English / Spanish / German / Portuguese / Chinese /Japanese
      17El árbol de los recuerdos / The memory tree2013Nube ochoBritta Teckentrup/United Kingdom0FoxFriend03English/ Spanish
      18El camaleón malcarado / The ugly chameleon*2015EldelvivesXan LópezSpain0ChameleonMain character00Spanish
      19El jardín de mi abuelo / My grandad's garden*2007BellaterraM.Ángels Gil/Mabel PiérolaSpain1BoyGrandfather10Spanish
      20El lenguaje de los arboles / The trees' language*2015FineoPepa Horno/ Martina VandaSpain1BoyGrandfather12Spanish
      21El niño de las estrellas / The kid from the stars*2000ING edicionsPatrick Somers/Katrien van der GrientBelgium0GirlBrother10Spanish/ Dutch
      22El pájaro muerto / The dead bird2018CorimboMargaret Wise Brown/ Christian RobinsonUnited States0ChildrenBird10English /Spanish
      23El pato y la muerte / Duck, death and the tulip2007Barbara FioreWolf ErlbruchGermany0DuckMain character10English / Spanish / German / Turkish /Japanese
      24En todas partes y en cualquier lugar / Everywhere and all around2017UranitoPimm van Hest/ Sassafras De BruynBelgium0GirlMother12English / Spanish / Dutch / Italian / Turkish / Polish / Romanian / German
      25Encender la luz / Turn on the light2018Babidi-búRaquel Castaño González/Marta López PalomoSpain1GirlGrandfather00English / Spanish
      26¡Gracias, vida! / Thanks, life!2017Babidi-búRosa María Rodríguez Tellez/Lucía García BorrajoSpain0GirlMother12English / Spanish
      27Háblame de ella / Tell me about her*2021Babidi-búSílvia García/Noelia MontesinosSpain0GirlGrandmother03Spanish
      28Huesos / Bones*2020Fun readersTxabi Arnal/Julio Antonio BlascoSpain00Pet00Spanish
      29Iliana, la Girl que escuchaba al viento / Iliana, the girl who heard the wind*2015BruñoAntonia Rodenas/ Carme SoléSpain0GirlMother00Spanish
      30Inés Azul /Agnes Blue*2009ThulePablo Albo/Pablo AuladellSpain0GirlFriend00Spanish
      31Jack y la muerte / Jack and the death*2012OqoTim Bowley/Natalia PudalovUnited Kingdom0BoyMother10Spanish / French / Italian / Portuguese
      32Julia tiene una estrella / Julia has a star*2006LaGaleraEduard José/Valentí GubianasSpain0GirlMother00Spanish /Catalan
      33La cabina de teléfono en el jardín del señor Hirota / The phone booth in Mr. Hirota's garden2021A fin de cuentosHeather Smith/Rachel WadaCanadá0BoyFather03English / Spanish
      34La caricia de la mariposa / The caress of the butterfly*2008KalandrakaChristian Voltz,France0BoyGrandmother00Spanish / French
      35La estrella de Lea / Lea's star*2008SMClaude K. Dubois and Patrick GilsonBelgium0BoyFriend10Spanish / Catalan / French / Japanese
      36La isla del abuelo / Grandad's island2015AndanaBenji DaviesUnited Kingdom0BoyGrandfather00English / Spanish / French / Dutch / German
      37La Girl y el árbol de las grajillas / The girl and the jackdaw tree*2004GalimatazoRiitta Jalonen/Kristiina Louhi (illustrator)Finland0GirlFather13Spanish / French / Polish / Finnish / Swedish
      38¡Mamá! / Mom!*2006EdebéIñaki ZubeldiaSpain0GirlMother13Spanish
      39Más allá del gran río / Beyond the great river*2002JuventudArmin Beuscher/ Cornelia HaasGermany0RaccoonFriend10Spanish / German / French / Japanese
      40Mi abuelita ya no está / My grandma is gone*2017Siruela ilustradaLili La BaleineFrance0GirlGrandmother10Spanish / French
      41Mi amigo el sauce / Gentle willow: a story for children about dying2008Sana colita de ranaJoyce C. Mills/Cary PilloUnited States1SquirrelPlant00English / Spanish
      42Nana vieja / Old pig1995EkaréMargaret Wild/Ron BrooksAustralia0PigGrandmother00English / Spanish
      43No es fácil, pequeña ardilla / It's not easy, little squirrel*2003KalandrakaElisa Ramón and Rosa OsunaSpain0SquirrelMother13Spanish
      44No puedo dormir / My father's arms are a boat2009Barbara FioreStein Erik Lunde/ Oyvins TorseterNorway0BoyMother00English / Spanish / Norwegian
      45Osito y su abuelo / Little bear's grandad1999TimunmasNigel Gray/Vanessa CabbanUnited Kingdom0BearGrandfather00English / Spanish / French
      46Para siempre / Always and forever2003Timun masAlan Durant/Debi GlioriUnited Kingdom0AnimalsFriend03English / Spanish
      47Para siempre /Forever2016La fábrica de librosCamino GarcíaSpain0Girl013English / Spanish
      48Paz. Papá se fue sin avisar / Paz. Dad left without warning*2011SirpusPaulina VergésSpain1GirlFather12Spanish
      49¿Por qué papá ahora es una estrella? / Why is dad now a star?*2015Círculo rojoCristina CastroSpain0BoyFather10Spanish
      50¿Qué viene después del mil? / And what comes after a thousand?2005TakatukaAnette BleyGermany0GirlGrandfather10English / Spanish / Japanese
      51Soy la muerte / Life and I2017Barbara FioreElisabeth Helland and Marine ScheneierNorway0Unspecified010English / Spanish / Swedish / Polish
      52Te encuentro en el arcoíris / I meet you at the rainbow*2021Mr. momoRocío Valderas/ Francisco Jiménez ArandaSpain0GirlGrandmother00Spanish
      53Tim dice adiós a su abuelo / Tim says goodbye to his grandfather*2019Mr. momoMac Freixas/Míriam SantosSpain0BoyGrandfather03Spanish
      54Tres pececitos / Three little fishes*2020Mr. momoGema Valado Fundín; Zaida Montes (illustrator)Spain0FishSiblings02Spanish
      55Un pellizco en la barriga / A pinch in the belly*2017Babidi-búAlma Serra; Marta López Palomo (illustrator)Spain1Girl003Spanish
      56Yo quiero saber de verdad qué es la muerte! / I wanna know what death truly is*2019TakatukaMonsieur Mouch; Maria-PazFrance0ChildrenBird10Spanish / French
      *At the time of the study there is no English version available, therefore, the title is a translation of the Spanish title translated by the authors.
      0: No; 1: Yes; 2: Grief as a short process; 3: Grief as a long process.
      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 titleSynopsisSupport materials included with the book
      3Así era mi abuelitoThis 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
      7Caramelos masticablesThe 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
      13Delfín, una historia de principio a finThrough 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.
      19El jardín de mi abueloThrough 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
      20El lenguaje de los arbolesThe 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
      25Encender la luzNaiara 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
      41Mi amigo el sauceThe 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
      48Paz. Papá se fue sin avisarThrough 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.
      55Un pellizco en la barrigaThe 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

      Characteristics of the main character

      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).
      Table 3Characteristics of the main character.
      CharacteristicFrequency%
      Type of main character
       Girl2341.1
       Boy1425.0
       Animal1323.2
       Undefined35.4
       Others35.4
      Ethnicity of main character
       White3692.3
       Black12.6
       Asian12.6
       Roma12.6
      Disability of main character
       No56100
      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).
      Table 4Approach to death.
      Frequency%
      Who dies?
       Grandfather1323.2
       Grandmother814.3
       Mother814.3
       Father610.7
       Friend58.9
       Plant/tree/animal47.1
       Main character47.1
       Brother/a35.4
       Pet23.6
       Others35.4
      Who communicates death to the protagonist?
       Not specified3562.5
       Mother1119.6
       Parents47.1
       Father35.4
       Grandmother11.8
       Grandfather11.8
       Family11.8
      Where does he/she die?
       Not specified2748.2
       In nature (field, river, sea…)1221.4
       At the hospital916.1
       At home814.3
      What is the cause of death?
       Not specified2646.4
       Disease1832.1
       Old age610.7
       Accident58.9
       Suicide11.8
      Are funerary rituals shown?
       No3867.9
       Yes1832.1
      What is death associated with?
       Not specified24.042.9
       Travel11.019.6
       Star9.016.1
       Sleep4.07.1
       Transforming into an animal3.05.4
       Go to heaven3.05.4
       Others2.03.6
      How many characteristics of death are shown?
       One1526.8
       Two2748.2
       Three47.1
       Four47.1
       None610.7
      What characteristics of death are shown?
       Irreversibility4644.7
       Causality3029.1
       Universality1817.5
       Non-functionality98.7
      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 NoSpanish titleCoping strategya
      1Abuela de arriba, abuela de abajo1,3
      2Al otro lado0
      3Así era mi abuelito1
      4¡Buenas noches, abuelo!1,2,3
      5Camila y el abuelo pastelero1,2,4
      6Camila, ¡regresa, abuelito!0
      7Caramelos masticables1,2.3,5,7
      8Casi, casi7
      9¿Cómo es posible? La historia de Elvis2,3,5
      10Copito de nieve0
      11Cuando la muerte vino a nuestra casa3,5,7
      12Cuerpo de nube1
      13Delfín, una historia de principio a fin1,2,5
      14¿Dónde está el abuelo?3.5
      15El abuelo de Tom ha muerto1,2,3,5
      16El ángel del abuelo0
      17El árbol de los recuerdos1,2,3,7
      18El camaleón malcarado1
      19El jardín de mi abuelo1,4,5
      20El lenguaje de los arboles1,2,3,7
      21El niño de las estrellas1,2,4,5,7
      22El pájaro muerto1,5
      23El pato y la muerte4
      24En todas partes y en cualquier lugar1,2,3,4,7
      25Encender la luz1,2
      26¡Gracias, vida!3,4
      27Háblame de ella1,2,3,7
      28Huesos1,2,3,7
      29Iliana, la niña que escuchaba al viento1,2
      30Inés Azul0
      31Jack y la muerte5
      32Julia tiene una estrella1
      33La cabina de teléfono en el jardín del señor Hirota12
      34La caricia de la mariposa1
      35La estrella de Lea1
      36La isla del abuelo1,5
      37La niña y el árbol de las grajillas1,2,3
      38¡Mamá!1,2,3,5,6,7
      39Más allá del gran río1,2,3,5,7
      40Mi abuelita ya no está1
      41Mi amigo el sauce1,3,6
      42Nana vieja5,6
      43No es fácil, pequeña ardilla1,2,3
      44No puedo dormir3
      45Osito y su abuelo3
      46Para siempre1,2,3,7
      47Para siempre1,4
      48Paz. Papá se fue sin avisar1,2,3
      49¿Por qué papá ahora es una estrella?1
      50¿Qué viene después del mil?1.3
      51Soy la muerte8
      52Te encuentro en el arcoíris1
      53Tim dice adiós a su abuelo1,3
      54Tres pececitos3,7
      55Un pellizco en la barriga1,2,5,7
      56Yo 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.

      Discussion

      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 (
      • Arruda-Colli M.N.F.
      • Weaver M.S.
      • Wiener L.
      Communication about dying, death, and bereavement: A systematic review of Children’s literature.
      ). 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
      • Arruda-Colli M.N.F.
      • Weaver M.S.
      • Wiener L.
      Communication about dying, death, and bereavement: A systematic review of Children’s literature.
      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 (
      • Patterson S.E.
      • Verdery A.M.
      • Daw J.
      Linked lives and childhood experience of family death on educational attainment.
      ), an experience that has been more frequent with COVID19 (
      • Livings M.
      • Smith-Greenaway E.
      • Margolis R.
      • Verdery A.M.
      Bereavement & mental health: The generational consequences of a grandparent’s death.
      ). 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 (
      • Alvis L.
      • Zhang N.
      • Sandler I.N.
      • Kaplow J.B.
      Developmental manifestations of grief in children and adolescents: Caregivers as key grief facilitators.
      ;
      • Chachar A.S.
      • Younus S.
      • Ali W.
      Developmental understanding of death and grief among children during COVID-19 pandemic: Application of Bronfenbrenner’s bioecological model.
      ;
      • Ferow A.
      Childhood grief and loss.
      ). In addition, during the school stage, children may somatize their feelings (
      • Revet A.
      • Bui E.
      • Benvegnu G.
      • Suc A.
      • Mesquida L.
      • Raynaud J.P.
      Bereavement and reactions of grief among children and adolescents: Present data and perspectives.
      ). However, the representation of somatization of their emotions is minimal in the set of coded stories.
      In relation to the causes of death, accidents, which are the element most cited by children as a cause of death (
      • Melvin D.
      • Lukeman D.
      Bereavement: A framework for those working with children.
      ) 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 (
      • Kenyon B.L.
      Current research in Children’s conceptions of death: A critical review.
      ).
      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 (
      • Zisook S.
      • Shear K.
      Grief and bereavement: What psychiatrists need to know.
      ). 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 (
      • Worden J.W.
      Grief counseling and grief therapy: A handbook for the mental health practitioner.
      ).

      Conclusion

      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 (
      • Arruda-Colli M.N.F.
      • Weaver M.S.
      • Wiener L.
      Communication about dying, death, and bereavement: A systematic review of Children’s literature.
      ;
      • Suvilehto P.
      • Kerry-Moran K.J.
      • Aerila J.A.
      Supporting children’s social and emotional growth through developmental bibliotherapy.
      ). 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.

      Appendix A. Supplementary data

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