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Magical Thinking Children may blame themselves for a parent’s illness and death Posted 1/24/2005

Early in the 20th century, British author Francis Thompson observed that to be a child is to be something “very different from the man of today.

“It is to believe in love, to believe in loveliness, to believe in belief…

“It is to be so little that the elves can reach up to whisper in your ear…

“It is to turn pumpkins into coaches, and mice into horses, lowness into loftiness and nothing into everything…”

That’s the sunny side of how children then and now may perceive the world.

There’s also a sinister side…a dark dimension where simple objects and actions might mold misfortune or lead to loss…a ruinous realm where a child’s tiniest misstep might unleash the pernicious power of, say, a grilled cheese sandwich. Such was the belief of little Breanna after learning her mother was seriously ill.

“When her mother was diagnosed with a brain tumor, Breanna thought she had caused it by eating the wrong half of a grilled cheese sandwich on a given day,” says Pauline King, an advanced practice registered nurse in mental health, and director for children’s programs at The Ohio State University Arthur G. James Cancer Hospital and Richard J. Solove Research Institute. “For a long time, she would pinch herself to cause noticeable marks on her arms as a punishment.”

The child was far from alone in her reasoning. King also recalls a young boy named Daniel who believed that, if only he had done better in school,

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his father wouldn’t have had to yell at him so much about his grades and thus may not have gotten cancer.

Then there was Matt, a 7- year-old who, after his father’s death, became “the perfect child” – so much so that his behavior was unsettling to those around him. King says he later confided his belief that, “if he could be absolutely perfect, maybe his dad would come back.”

Michael Puleo was 5 years old when his father died of recurrent melanoma, and for a long time he thought he was responsible for his dad’s death. “He had no particular reason; it was just a sense of responsibility that he felt,” says his mother Dottie Puleo, RN, coordinator for dialysis at Mount Carmel Hospitals in Columbus, Ohio.

“After his father died, I was quite concerned for about a year, because in Michael’s mind, he thought we could all go with his dad – me and him and the dog. He didn’t have that sense of finality for dying and going to Heaven.”

All of these children, and countless others like them, were bound by an emotional thread recognized by some mental health clinicians as “magical thought,” a distortion of reality that may signify a complex and potentially harmful mourning process.

In his book, The Magical Thoughts of Grieving Children (Treating Children with Complicated Mourning, and Advice for Parents), author James A. Fogerty, EdD, defines magical thought as “children’s inaccurate conclusion (s) regarding a loss experience resulting in children believing that they are responsible for the loss and need to fix (it).

“Magical thought may lead children to believe that they have developed a method of mourning, but they have actually developed an unhealthy and complicated process of mourning,” writes Fogerty, a clinician, licensed clinical psychologist, certified school psychologist, author and nationally known lecturer on children’s grief and bereavement.

In his introduction, Fogerty says magical thought is so powerful that, for some children, it could lead to personality disorders as they mature. His book offers a model of magical thought that he developed “to help with the treatment of children who are experiencing a dysfunctional and complicated process of grief and mourning.”

King has a copy of Fogerty’s book, she has heard him lecture, and she embraces his concept of magical thought. “He’s a dynamic speaker,” she says, “and he affirmed a lot of what we are doing with our own children’s programs here at OSU’s James Cancer Hospital.” King herself is widely acknowledged as a pioneer of programs that support children through the illness and death of loved ones—programs based on her simple but sound premise of “listening to children and honoring their pain.”

That premise was the subject of a presentation she delivered at the Oncology Nursing Society (ONS) 28th Annual Congress in Denver, Colo., as recipient of the 2003 ONS Foundation Mara Mogensen Flaherty Memorial Lectureship. The lectureship honors a health care provider who has made a

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substantial contribution to the psychosocial aspects of cancer care.

“Ten years ago there were few if any programs for grieving children, and there aren’t many now, because children have long been a forgotten population at times when someone close to them is experiencing illness and death,” King says. “They may look like they are coping well to adults who see them at play, because adults equate play with being care free. But the truth is that children need to be heard during the traumatic experience of illness or death of a family member. Grieving is a life skill, and children must be given a chance to exercise it properly to avoid problems later.”

Because children don’t see the world as adults see it, King says, they grieve differently than adults, and their need to express is better served through art than words.

“Young children think concretely, which lends itself to accepting and maintaining inaccurate assumptions and pro m o ting magical thought about serious illness and death,” she explains. “A group of children of any age cannot sit in a circle and tell you how they feel about illness or death. They lack the cognitive development to express their fears and emotions with words. But if they are given the means to express themselves through art, their expression of pain and subsequent healing can be remarkable.”

Over the past decade at The James Cancer Hospital and Solove Research Institute, King has developed a continuity of care model to help children cope with a loved one’s illness and to grieve properly for up to several years after a loved one’s death.

Her model, which serves more than 250 children per year, encompasses three support groups that have evolved from feedback obtained from the kids who participate.

Hand in Hand – This sixweek program helps children ages 2-19 cope with the serious illness of a loved one from diagnosis to death. The children are separated into age-related groups (2-7, 8-12 and 13-19). Although most have relatives with cancer, the group is open to any child experiencing serious illness within the family, no matter where the person is being treated. A support group for adults is conducted while the children are in group sessions.

“Children need and want to know how to adjust to the myriad of changes they will encounter during the illness,” King says. “One young boy, after attending the second session of this program, told us he hadn’t wanted to come at first, but that now he felt like a bowling ball had left his stomach.”

She says parents often

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report that, when children participate in this group (which they may rejoin as often they like throughout someone’s illness), their grades improve, they have less developmental regression such as incontinence, and they demonstrate less “acting-out behavior,” separation anxiety, fear and anger.

“We also teach parents how children grieve and how to help them cope with their emotions and fears,” King says. “Although this needs to be researched, we have found that children and adults who have attended this group throughout the illness continuum adjust better when a family member dies than when they enter our program at the end-of-life stage or post-death.”

Good Grief – Also six weeks long, this program helps children cope with the death of a loved one from long-term illness, heart attack, traffic accident, suicide or any number of other causes. Because grief is a family experience, Good Grief also offers a support group for adults while the children are in session.

Kids in this group learn about grief and how to cope with it. “Children are much more natural and instinctual about grieving once they understand the process,” King says.

“We use the metaphor of waves to help them identify the emotions of grieving. When someone they love dies, it may seem like the waves of grief are hitting them frequently and hard, but as time passes the waves will hit less frequently and less hard.”

Marie Lang, a registered and board-certified art therapst who is primary facilitator for Good Grief, says her role is to give children a safe place to express their feelings about the loss and to help them find ways to work through it and discover hope for living without the departed. Her chief means of doing this is through art.

“Children don’t talk about grief for long periods like adults; they grieve in spurts,” Lang says. “When they’re doing it in connection with an art activity, they feel more comfortable and in touch with what they’re feeling. Everything they create is really a self-portrait.

“It’s not deeply profound what we’re doing,” she adds. “We’re just giving them a chance to express themselves and helping them bring their feelings into the open so that, if they have any harmful ‘magical thoughts,’ we can correct them.”

Their art activities include drawing, sculpture and making “remembrance quilts.”

During the first week, Lang explains, the kids bring in photos of the deceased. “We sort through them, lay them out on a sheet of paper, and talk about memories connected to them. Sometimes it’s really hard and they’ll cry, so I always end by asking them to tell us a funny story about their loved one.”

In the second week, the kids bring in mementos of the departed. “This

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could be a range of things, from seashells to cards, all of which can be attached to the quilt,” Lang says, noting that the children can also affix new drawings and messages. “The kids use all of these materials to design their remembrance quilts with tape and pins. Then a professional quilter fashions it all into a quilt that they receive during the final week.”

The children are comforted by these lasting keepsakes.

“To see their faces when they receive their quilts is something to behold,” King relates. “The quilts help them remember and honor their loved ones throughout life. They are a child’s view of what was important about their relationship at the time of death.”

Lang considers it a privilege to help young people at a difficult time in their lives.

“I lost my first son, Isaac, at age 16 months, so I know how difficult it is to grieve,” she says. “A year after he died, I met Pauline at the North Market where I had a stall with some of my paintings. She bought one and asked me to come and work with her. It was sort of serendipitous, and it has helped me very much with my own healing.”

Parents who need help grieving and assistance in helping their children grieve can benefit from Good Grief’s adult group component led by Esther Hampton, who has a PhD in counselor education from Ohio State and has worked with King for years.

“We help adults work through their own grief and teach them ways to help children deal with theirs,” Hampton says.

“Very often the way children grieve is invisible to adults. Many don’t realize that children grieve differently, so they don’t give them the space and time they need to work through it. They see kids playing and think, ‘Oh, they’re fine.’ But parents need to know that what they’re seeing in their children may not be what’s actually going on in their children.”

She says parents need to appear less cavalier about loss and be more emotionally available to their children. “We don’t want children to be left in a backwater of emotional distress without anyone noticing.”

King agrees. “We encourage parents to cry with their children,” she says. “One father told me he tried to be strong and protective by not crying in front of them. One night when it was clear his wife was not going to make it, he was rocking them on his lap and started to tear up. His daughter said, ‘Daddy you’re sad too?’ When adults cry it gives their children permission to cry and to talk about their fears.”

Good Grief and Beyond – After completing Good Grief, children are invited to join this monthly support group that helps them honor their loved ones through the year’s events, holidays and anniversaries. An adult group also meets with this program.

“This group has become an extended family,” King says. “Some of these kids have been together for up to five years and are great friends. The

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children have dinner together, talk about new occurrences in their lives, and participate in art activities that honor their loved ones in relation to the passing seasons and holidays.”

Some of the children wrote and produced a book called Honoring Pain to help other kids feel less isolated by grief. They dedicated the book to children affected by the terrorist attacks of Sept. 11, 2001, in New York City. Ohio Gov. Bob Taft sent the book to the governor of New York, who sent it to New York City Mayor Michael Bloomberg. The mayor asked for 500 copies to be placed in a private viewing room at Ground Zero.

In another project, kids in this group made “comfort cards” to share with other children experiencing loss and grief.

“We recognized that manufacturers did not make cards to give children facing the death of a loved one,” King says. “We told our kids that they would be best suited for designing sympathy cards for kids since they knew what a child may want to hear at a time of loss.”

Working with artists and poets, the kids designed cards with written sentiments that King believes are very different from adult cards. “For example,” she says, “one child wrote: ‘No one ever leaves all the way. They leave little pieces for family and friends to find and discover.’”

King says the ultimate goal of her carefully crafted continuity of care programs is to guide children safely through an early life challenge, uncovering harmful “magical thoughts” and working to correct them, however long it takes.

“Sometimes it’s months or even years before we hear a child say, ‘I know that it wasn’t my fault,’” King says. “Our group structure not only allows a child to hear corrected magical thinking from other children, but it also gives us the opportunity to join with the parent in being aware of these thoughts and supporting the correction. We need to honor our children’s pain by witnessing it and bearing it with them.”

At the end of each session of Good Grief and Good Grief and Beyond, the kids gather together for a closing ceremony where they release balloons bearing handmade pictures and messages to their loved ones.

“We all stand there and watch those balloons go as far as we can see them go,” King says. “Some of the kids really believe the balloons are heading up to Heaven.”

At one of those closing ceremonies three years after entering the program, Michael Puleo acknowledged that he was not at fault for his father’s death. In fact, his mother Dottie recalls, he wrote that message on one of the balloons.

“Those ceremonies were pretty important to him,” she says. “At first he believed the balloons were going to his father; he wanted to hook pancakes on them because his daddy loved them so much.”

She has no doubt that King’s programs have helped her and her son move

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on. “I don’t think we’d be the people we are today if not for Pauline.”

“I sometimes worry that we’re feeding back into ‘magical thought’ with our closing ceremony,” King laughs, “but the kids all love it. It gives them comfort and makes them feel like they can still communicate with those who have left them.”

Watching the waves of messenger balloons drift into the heavens, King and colleagues can also find comfort in knowing they have helped aggrieved children regain their ability to, in the words of Francis Thompson, turn lowness into loftiness. ■

Written by Bob Hecker Photography by Roman Sapecki

Honoring Pain is a collection of artwork by children and insightful essays by art therapiests, grief counselors, group facilitators and others working with the OSU James Cancer Hospital children's program. It is an excellent resource for parents, teachers and health-care workers.

The Little Book of Love is designed or adults to let their children or grandchildren know how they feel about them; it is a way for families to keep the feelings they have for each other forever. If you had only 48 hours to live, what would you say to your children or grandchildren?

The books are $20.00 each, or $17.50 each when ordering two or more, plus shipping and handling ($2.00 for 1-2 books, $3.00 for 3-4 books, $4.00 for 5-6 books, and $5.00 for 7-10 books). To place an order, write to:

Pauline King, Director, Children's Programming The James Cancer Hospital and Solove Research Institute 300 West 10th Ave., Room 519 Columbus, OH 43210

CHILDREN’S PROGRAMS RECEIVE BATTELLE GRANT

Pauline King, director of children’s programs at The Ohio State University Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, has received a five-year $500,000 challenge grant from Battelle Memorial Institute to support her nationally recognized children’s programs. The programs help children cope with the death or impending death of a parent from cancer.

“Most adults don’t know how to grieve, and children grieve differently from adults,” says King, a registered nurse and a pioneer in helping grieving children using art and other therapeutic forms of expression.

“Children who don’t

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grieve properly following a loved one’s death to cancer or other cause are at increased risk for depression, anxiety and bad grades. It can even affect them later in life with job failure and inability to bond or be intimate with another person.”

King’s programs include “Hand-in-Hand,” in which children learn about the loved-one’s illness, how to manage changes in their lives and accept and cope with their emotions. They receive support from other children going through the same experiences.

“Good Grief and Beyond” helps children coping with the death of a loved one. During the year-long program, children learn to express their feelings of loss through forms such as art, music, dance, poetry and photography.

“The Balloon Brigade” offers children an educational tour of the OSU James Cancer Hospital and Solove Research Institute. The program familiarizes children with the hospital environment and cancer treatment, and teaches them about cancer prevention.

“I'm so thankful to Battelle for seeing this as an important investment in our children," King says.

Photo by Jo McCulty

Pauline King and children from a recent Hand-in-Hand program.

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