Grand Valley State University
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Graduate Research and Creative Practice
1998
The Concept of Death Education on Children's Understanding of Death Diana K. Clark Schramm Grand Valley State University
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THE CONCEPT OF DEATH E DUCATION ON CHILDREN'S UNDERSTANDING OF DEATH
By
Diana K. C L A R K SCHRAMM
A THE SIS S u b m i t t e d to Grand Val l e y State University in partial fulfillment of the requirements degr e e of
MASTER O F SCI ENC E
for the
IN NURSING
Kirkhof School of Nursing
1998
The sis Committee Member: Cy nt h i a Coviak, Sh ar o n Leder,
Ph.D.,
D.S.N.,
Daniel Hendrickson,
R.N, R.N.
M.S.W.
ABS T R A C T THE C ONC E P T O F DEATH E DU C A T I O N ON CH IL DRE N'S UNDERSTANDING OF DEATH By Diana K. C l a r k Sch ra mm
The p u r p o s e of this i nv est i g a t i o n was to determine if d e at h education has an impact on child ren 's un derstanding of death. This study was a n o n - r a n d o m i z e d trial of a single educational session on d e a t h concep ts of 38 second grade children 7.78 y e a r s ) .
(mean age
The S m i l a n s k y Death Con ce pt Questionnaire,
validated a n d p u b l i s h e d i nte rv i e w i n g tool, and post i n t e r v e n t i o n to all study subjects un der sta nd ing of death.
a
was administered preto evaluate their
This int erv e n t i o n was a story on death
and a peer g r ou p discussion. Posttest scores were s i g n i f i c a n t l y higher than pretest scores for h u m an d e a t h concept,
and animal death concept,
well as on the total de ath concept.
as
There were no significant
relationships b e t w e e n d e m o g r a p h i c variables and the Smilansky Death Concept scores.
It is r e c o m m e n d e d that elementary schools
consider i n c o r p o r a t i n g a d e ath e du c a t i o n p r o g r a m into their current curriculum.
Dedication This thesis is d e d i c a t e d to my husband, daughters,
Katelin and Kristen.
understanding, reality.
Greg and my
Without their love,
and sacr if ice s my d ream may never have become a
Acknowledgments
I have m a n y people to gra teful to for supporting and encouraging me through m y m asters program.
I would like
to express my deepest a p pr eci ati on to my committee. Their support and avai la bil ity has enabled me to meet m y goals and complete this project. thank Linda Scott R.N., never ending patience,
M.S.N.,
I would also like to PH.D.
expertise,
Candidate,
and a v a i l a b i l i t y .
Special thanks goes to m y parents, and e xceptional when I did not.
for her
extended family,
friends who always believed in me even To my mother for providing me with the
extra hands and understanding I n e ed ed to complete m y education. My most sincere thanks go out to my friends, Jennifer Jordahl and Debbie Provoast.
These true friends
were with me through the thick and thin of graduate school.
Thei r support and love gave me strength to r eac h
for the stars!
Table of Contents
List of T a b l e s ................................................. vi List of F i g u r e s ...............................................vii List of A p p e n d i c e s .......................................... viii CHAPTER 1
IN TRODUCTION Intro du cti on ........................................ Purpose .............................................. Re se arc h Question .................................. N u r s i n g Implications ...............................
1 5 5 5
2
C O N C EPT UAL FRAMEWORK AND REVIEW O F LI TERATURE Theory: Jean Piaget ............................... 7 Re vi e w of Literature .............................. 11 Studies on Developmental Level and Death Understanding .................... 11 Studies on the Death E du c a t i o n and Its E f f e c t s ...............................16 S u mmary and Implications for S t u d y ....... 24 Hypothesis ................................... 25 Definition of T e r m s ..........................25
3
METHODS R es ear ch Design ................................... 26 Sample and Setting ................................29 I n s t r u m e n t .......................................... 32 P r o c e d u r e ........................................... 36
4
R E S U L T S ................................................ 4 0 Other Findings of I n t e r e s t ....................... 44
5
DIS CUSSION AN D IMPLICATIONS Di sc uss ion of Findings ........................... 46 Re l a t i o n s h i p to Conceptual F r a m e w o r k .......... 51 L i m i tat ion s of the S t u d y .......................... 53 Re co mme nda ti ons ................................... 54 R e s e a r c h .......................................54 Nu rs i n g Education ........................... 57 Nurs i n g Practice ............................ 58
IV
Summary and
C o n c l u s i o n ......................... 59
A P P E N D I C E S ...................................................... 61 R E F E R E N C E S ...................................................... 79
List of Tables
TABLE 1
C h a r a ct eri sti cs of S u b j e c t s ............................. 31
2
S um mar y of Smilansky Death Concept Scores ............. 41
3
C om par iso ns of Pre- and Posttest Death Concept S c o r e s .................................... 42
4
C o m p a r i s o n of Demographics and Death Co nc ept Scores .......................................... 43
VI
List of Figures
FIGURE 1
Piaget:
Con ceptual Framework
Vll
8
List of Appendices
APPENDIX A
Consent to Use Piag et Conceptual F r a m e w o r k ............................... 61
B
Human Subjects R e v i e w Committee A p p r o v a l ....... 62
C
Elementary S c h o o l Ap p r o v a l ......................... 63
D
Letter to the P a r e n t s ............................... 64
E
Consent Forms .......................................
F
Personal Data S h e e t ................................. 68
G
Consent from Dr.
H
The Smilansky D e ath Concept Q u e s t i o n n a i r e ........ 71
I
Smilansky's S c o r i n g T o o l ........................... 74
J
Pretest Script ...................................... 75
K
Intervention Q u e s t i o n s ............................. 77
L
Posttest s c r i p t ...................................... 78
66
Sara S m i l a n s k y ................... 70
Vlll
CHAPTER 1 I N TRO DU C T I O N
Death is a reality that all h uman beings must end ur e at one time or another.
As adults,
difficult to fully comprehend.
d eath is complex and
C h i l d r e n have fewer life
experiences and limited c og n i t i v e d evelopmental skills integrate death.
to
Children r e q u i r e intellectual
understanding of death before t h e y can effectively process
it emotionally.
This u n d e r s t a n d i n g of
me an ing of death is essential progress
the
for the grieving process to
(Schonfeld & Kappelman,
1990).
Age-appropriate
edu cat io n can help adults and c h i l d r e n process and prepare for the death experience. Ac c ord in g to the w i s d o m of Buddha, we can actually use our lives to prepare for death. We do not have to wait for the painful d e a t h of someone close to us or the shock of terminal illness to force us into looking at our lives. Nor are we condemned to go out em pty-handed at d eath to meet the unknown. We can begin, here and now, to find m ean i n g in our lives. We can make e very m o m e n t an opportunity to change and to prepare, wholeheartedly, precisely, and with peace of m ind for d eath and eternity (Rinpoche, 1992, p. 257). Parents want to p rotect t h e i r c h il dre n from the emotional pain death causes.
However,
it is inevitable
that children are exposed to death.
Children will n eed
to accept and understand death as a natural process of life.
Learning about death may help children to be
better prepare d to cope with their emotions and d ecr e a s e their fears. A s s oci ate d fears or anxieties can c o m p o u n d children's mis conceptions about death.
Death e d u c a t i o n
can clear these misconceptions and help the children understand death at their dev el opmental level (Labinowicz,
1980) .
Education c ou ld help children
understand that the feelings they m a y have are normal. It may help them understand the behavior of others who have ex perienced a death
(Jones,
Hodges,
& Slate,
1995) .
A growing movement exists to implement death education programs in elementary and secondary schools. The growing number of deaths in school-age children supports this movemen t
(Jones et al.,
1991),
The three
leading causes of death in school-age children are accidents,
suicide,
and unexpected
and homicides
(Jones et al.,
that are usually sud den
1991).
Many schools
provide grief counseling for c h il dre n after a tragic death occurs in a co mmunity as crisis intervention. example,
crisis
For
intervention was provid ed when a local
Michigan high school experienced three unrelated student deaths within one school year. school district,
In another Michigan
a fatal motor v ehicle accident c lai m e d
the lives of three grade school children.
Each of the
schools p r o v i d e d one day of grief c o u n s e l i n g for their children,
and fu rt her counseling was p r o v i d e d as
appropriate for the children. of the questions, In an informal
emotions,
The teachers
fielded most
and tears in both situations.
sur ve y of seven e l e m e n t a r y teachers,
they
felt that if t h eir students had receive d death education prior to the loss,
it might have helped t h e m understand
and grieve more e f f e c ti ve ly Reed,
S. Dickerman,
(M. Hayes,
K. Wood,
personal communication,
V.Charles,
D. Southland,
February,
P.
D. Dudack,
1997).
The e m ot ion al and cognitive impact of death on children, changes,
who are experiencing normal devel opm en tal c rea te s enormous stress on those children.
Frequent b e h a v i o r changes, hopelessness,
such as crying,
s lee p disturbances,
irritability,
a g g r e s s i o n or a
decrease in a t t e n t i o n span occur in ch il d r e n who are having d i f f i c u l t y understanding d e ath
(Glass,
1991).
Direct r e l at ion shi ps between the stages of cognitive development,
as p r opo se d by Piaget,
understanding o f illness and death, (Kalnins & Love,
1982).
and children's can be determined
In a review of studies of
children's u n d e r s t a n d i n g of h eal th -re la ted issues, Kalnins and Love de t e r m i n e d that chil dr en' s concepts of understanding w ere influenced by personality,
family
hist or y and their own state of health, co gnitive development.
in a d d i t i o n to
Developmental stages,
de at h experience and education,
adjustment
p r evi ou s
(adaptation)
a n d effective coping skills must be c o n s i d e r e d when co un sel ing a child r e g a r d i n g death issues
(Glass,
1991).
Justification for d e a t h education in the sc hools is strong.
Yet,
it can a lso present ethical conflicts,
such as religious b e l i e f s and moral values.
Death
educa tio n also c reates b a r r i e r s by d e par tin g
from
traditional education,
w h i c h requires c u r r i c u l u m changes
and school board approval.
Because of these barriers,
op po sition to these n o n t r a d i t i o n a l programs exists. Death education p ro gra ms are often seen as b e i n g intrusive into mat t e r s of family r e s p on sib il ity and faith (Glass,
1991).
For the programs
to be successful,
parental support is es sential.
obtaining
Parents are l i k e l y to
have misconceptions a b ou t a death and u n d e r e s t i m a t e children's un de rs t a n d i n g of death
(Jones et al.,
their
1991).
Oppo si tio n to death e d u c a t i o n may also occur b ec a u s e
the
parents do not want to ac ce p t their own m o r t a l i t y or fears. child re n
Often these a n x i e t i e s are passed on to the (Jones et al.,
1991).
It is h igh l y im p o r t a n t to
educate not only the c h i l d r e n about death,
but to educate
their parents about d e a t h and the importance of d e at h
e d u c a t i o n for the ch i l d r e n
(Jones et al.,
1991).
recognizing the ef fe cti v e n e s s of death education, parents,
the health care provider,
In the
and the e du c a t o r can
pro v i d e support for the c h i l d r e n trying to u n d e r s t a n d d e a t h issues. Pu rpose and Research Q u e s t i o n The purpose of this s t u dy was to determine if death e d u c a t i o n has an impact on children's u nd ers t a n d i n g of death.
The following r e s e a r c h question was a d d r e s s e d to
gat her information r e g a r d i n g children's cognitive u n der st a n d i n g of death a n d the effects of de ath education: What effect does an educational session,
that
includes a story a d d r es sin g d e ath and subsequent peer g r oup discussion,
have on school age children's
u n d e rst and in g of death?
The findings of this study
pr o v i d e data useful for d e t e r m i n i n g if death ed uc a t i o n should be included in school age children's g eneral curriculum. N u r s i n g Implications A dv anc ed practice nurs es be advocates
(APNs)
are in a p o s i t i o n to
for c hi ld ren in p r o mo tin g death ed u c a t i o n
w i t h i n the school system.
N u r s i n g experts m a y act as
consultants for schools in e s tab li shi ng a c u r r i c u l u m that is d eve lo p m e n t a l l y appropriate.
APNs can counsel parents
who are assisting their c h i l d in understanding death.
understanding death.
Finally,
through c o nti nu ed research,
a d v a n c e d practice nurses,
ca n investigate implications
for children's understanding of conce pts related to death.
The effect that death e d u c a t i o n has on their
development m a y then be further d e t e r m i n e d and a p p l i e d in existing ed uca ti ona l curriculums 1990) .
(Schonfeld & Kappelman,
CHAPTER 2 CONCEPTUAL FRAMEWORK AND REVIE W OF LITERATURE
Current r es e a r c h suggests that children's understanding of d e a th evolves in a systematic predictable sequence,
based on their cognitive
developmental stage.
This is consistent with Piaget's
theory of cog nit ive development 1986) .
(Burback & Peterson,
School age children do have an increased
understanding of causality,
are less egocentric and have
an increased p er c e p t i o n of time than in earlier stages. Their ability to u n d er sta nd death is limited;
however,
this school age g r o u p can identify death as being concrete
(Glass,
1991).
Theory:
Jean Piaget
Piaget saw c o g nit iv e acts as a process of organization of a n d adaptation to the environment.
To
understand the pro ces s of intellectual org anization and adaptation,
Piaget identified four concepts.
concepts are schema, equilibrium
assimilation,
(Wadsworth,
Piaget's concepts,
1971).
These
accommodation an d
To further illustrate
a conceptual framework was d ev e l o p e d
and can be seen in F i g u r e Wong,
1
(see A p p e n d i x A ) ( W h a l e y &
1979). Schema is a c o g n i t i v e structure b y w h i c h individuals
intellectually a da pt
to a n d organize the environment.
Assimilation is d e f i n e d as new experiences into
inco rpo rat in g per ce pti ons of
the existi ng framework.
Accommodation is m o d i f y i n g existing structures, old structures.
E q u i l i b r i u m is an acti ve
new or
intellectual
balance with the e n v i r o n m e n t and is a c o m p l e m e n t a r y process operating
(Wadsworth,
1971) .
Figure 1 Piaget:
Conceptual
Framework D evelopm ent of hig h er level sch em a
E q u ilib riu m
A ccom m odation of p a s t to solve problem
A ssim ilation of th e new New experience
New experience New experience
\
E stablished sc h em a
Disequilibrium
A ssim ilation
(Used with permission,
N eed to solve problem
P ro c e ss co n tin u es to m aintain equilibrium th ro u g h o u t life
W h a l e y & Wong,
1979,
p.
68)
Piaget d e v e l o p e d theor ie s of stages t ha t evolve directly from the p r e v i o u s de vel opmental l e v e l .
As
c h ild ren grow and develop, progr ess
Piaget stated that they
through these stages.
There are four
developmental stages c o n s i s t i n g of: s e n s o r i - m o t o r stage, a p e r i o d of sensory input a nd c o ord ina ti on of p hys ica l actions
(0-2 years);
p r e - o p e r a t i o n a l stage,
representational and p r e l o g i c a l thought c o ncr ete operational stage, thought
a p e r i o d of
(2-7 y e a r s ) ;
a period of c on cr ete logical
(7-11 y e a r s ) ; and formal operational stage,
p e r i o d of unlimited lo gi cal thought (Labinowicz,
a
(11-15 years)
1980).
The developmental s tage specific to the age group of interest
in this s tudy is the phase of concr et e
o perational thought.
During this period c hi ldren's
rea son in g becomes more logical.
Children can process
logical thought or o p e r a t i o n s and apply them to concrete problems.
They can h o l d two or more variables
when evaluating data
(Labinowicz,
1980).
at a time
This me ans a
co mp lex issue can be e v a l u a t e d by assessing each variable s e p a rat ely and c omp aratively.
The child can then develop
a conclusion. At this stage,
c h i l d r e n are becoming more
increasingly aware of others'
views.
social and
There is rapid
g r ow t h in the ability to c o nse rv e properties of objects, such as numbers.
It is a lso a time when the c h i l d r e n can
pr es ent mental images of p h y s i c a l l y absent objects,
based
on memory.
However the thinking process remains
restricted to concrete things, (Labinowicz,
rather than ideas
1980).
Piaget identifies c hil dren's concepts of d ea th in each of his developmental stages. operational stage or school age, statements
In the concrete there are three
Piaget identified t hrough studies on death
conceptualization.
"Death is irreversible but not
necessarily inevitable. viewed as destructive.
Death m a y be personified and Expl ana tio ns
naturalistic and physiologic"
for death are
(Wong,
1996,
Piaget's concepts and c on c e p t u a l
p.
546).
framework can be
used to d evelop a similar frame wor k when studying children's understanding of d e a t h and death educat io n variables.
The views of death for developmental levels
of children are seen as the schema.
As children de vel op
their schema they continue to pr ocess new stimuli (Wadsworth,
1971).
Death is the new experience that is
incorporated into the framework and must be assimilated. Death education is the m e c h a n i s m of accommodation or modifying of structures to pr o g r e s s
into equilibrium.
Children's understanding of d e a t h then provides t he m with equilib ri um or balance within their environment. Followers of Piaget have implied that a child's matu rational sequence in the a cq uis it ion of the concepts
10
of death can be a lte r e d or a c c e ler at ed through direct intervention
(Schonfeld & Kappelman,
1990).
Review of L i t e ra tu re The review of literature focuses on the influential background r es ea rch that supports this
study.
This
section includes studies that review d e at h education programs and t heir influence on c h i l d re n's understanding of death-related issues.
It also includes articles that
review de vel opmental levels and u n d e r s t a n d i n g of death at those levels.
W h i l e there are m a ny s tud ie s evaluating
children's a d a p t a t i o n to death Speece, 1992),
1994; C o t t o n & Range,
(Atwood,
1984;
Brent &
1990; N o r m a n d & Mishara,
few ad dress the effect that d e a t h education can
have on children's understanding of death. Studies on Dev elo pm ent al Levels and U nde rst a n d i n g of Death Kane
(1979)
conduc ted the first of several studies
that investigated children's pe r c e p t i o n s or understanding of death based on developmental levels. open-ended questionnaire,
Kane,
using an
studied the m e n t a l development
of children ages 3-12 to determine their concepts of death and the impac t of experience on those concepts. The sample c o n s i s t e d of 122 white, female students.
m i d d l e - c l a s s male and
She determined th ro u g h her
questionnaire that an understanding of d eat h occurred by
11
age 6.
This was m u c h
estimate, Kane,
y o u n g e r than Nagy's
who th oug ht it occ u r r e d at age
1979).
(194 8) 9
(as cited in
She a l s o c o n c u r r e d that c h i l dre n' s concepts
of death develop as a f u n c t i o n of age and m a t u r i t y as in Piaget's d e v e l o p m e n t a l stages.
Additionally,
she found
that children 8 ye ars o l d and above were c o n sis te ntl y showing adult c o n c e p t s a b o u t death Kane believed,
as
Piaget,
(Kane,
1979) .
that c hil dren's
perceptions of d e a t h are d e ve lop ed in s e que nc e and through a series of s t a g e s research,
(Kane,
1979).
Kane e s t a b l i s h e d 10 categories
children's mental c o n c e p t s of death. include realization, irrevocability, universality,
separation,
ca usa lit y,
that addressed
T h e s e concepts
immobility,
dysfunctionality,
in sen s i t i v i t y ,
personification.
T h r o u g h her
appearance,
and
T o c o r r e s p o n d with these stages,
identified three s e q u e n t i a l developmental Piaget's de v e l o p m e n t a l
stages based on
st ag e s that she felt were
necessary for c h i l d r e n to understand death. are identified as
(a)
ages 7-9, and
stage
Smilansky
(c)
(1987)
she
s t a g e one, three,
ages 3-6,
T h es e stages (b)
stage two,
ages 10-12.
d e v e l o p e d a qu e s t i o n n a i r e to
evaluate the a ffects of children's u n d e r s t a n d i n g of death after the loss of t h e i r parents.
Her instrument,
Smilansky Death C o n c e p t Questionnaire,
12
the
was b a s e d on five
concepts related to ch ildren's u n d er sta nd ing of death: irreversibility, old age.
finality,
causality,
inevitability,
and
The in strument was composed of 26 op en -ended
questions,
13 r elated to the death of humans and 13 to
the death of animals.
Smil an sky included 948 children
ranging in age from 4-12 years in her r es ea rch study. There were 47 6 orphans, a control group.
and 47 2 non-orphans who served as
Al l of the children were interviewed
with the Smilansky D eath Concept Questionnaire.
The
interviewers also c o l l e c t e d such d e m o g r a p h i c data as age, sex,
and parent education.
Intelligence te sting
(I.Q.)
was also done. The results of Smilan sky 's study showed that the non-orphan control g r o u p averaged scores of 23.5 5),
while the orphans
a v era ged scores of 22
(SD =
(SD = 4.7)
in
total conceptua li zat ion of death and in d e a t h of humans. However,
there was no significant d i f f er enc e in these
groups in the c o n c e p t u a l i z a t i o n of animal d eath as determined by co m p u t i n g t-tests
(t = 1.94,
p > 0.05).
Smilansky felt that b eca u s e all demographic data were similar between the two groups,
the orphans c o ul d not
reach a higher c o n c e p t u a l i z a t i o n of human d e at h due to their personal,
e m oti on al experience with death.
She
felt that this was s u p p o r t e d by the fact that conceptualization of animal death was si mil ar in both
13
groups.
Smilansky felt that families in mou rning d i d not
always help children understand death.
She came to this
co nc lusion through a series of interviews with adults, who had been orphaned as children.
She theorized that
exper ien ci ng the death of a parent aids orphans in total death conceptualization, conce ptu al iza tio n process Speece and Brent
only if adults help with this (Smilansky,
(1992)
1987).
c o nd uct ed a study that
focused on the acquisition of three key components of death c on ceptualization in children:
universality,
ir r eve rs ibi lit y and non-functionality.
These components
were d e t e r min ed by an evaluation of 50 similar studies. Ninety-one children,
kindergarten through 3^^^ grade,
inter vi ewe d individually using a str uct ur ed tool. tool was develo pe d by the researcher,
the Smila nsk y Death Concept Q u e s t i o n n a i r e
including
(Smilansky,
Questions were d eveloped to determine the
un de rst and in g of all three components, short,
This
but was m o d e l e d
after several other e stablished instruments,
1987).
were
requiring simple answers.
Is it alive?;
and were very
Example questions are:
can a dead person breathe?;
and will they
come alive if you give them m e d i c ati on ? Most of the children un d e r s t o o d each component,
but
less than 50% achieved a mature und er s t a n d i n g of all three components.
The researchers
14
felt that due to the
fact that only 50% of the subjec ts had a mature understanding of all three components,
the process of
achieving an u n d ers ta ndi ng of d e a t h continues in c h i l d r e n through age 10.
Much of this s t u d y was concerned with
sequential a c q u i s i t i o n and c o n c u r r e n t acquisition, Piaget's th eo r y as a basis for this.
citing
Through this study,
it was d e t e r m i n e d that u n i v e r s a l i t y is understood initially,
and that i r r e v e r s i b i l i t y and n o n -fu nct io nal it y
are understood together in later d eve lo pme nt Brent,
(Speece &
1992).
Cotton a n d Range irreversibility, their study. ages 6-12.
(1990)
finality,
were
concerned with
c a u s a l i t y and inevitability in
T h e se researchers
i n t e r vi ewe d 35 children
Dem ographics were a c q u i r e d and four
questionnaires were used:
(1)
the
fear of death subscale
of the Fear S u r v e y Schedule for c h i l d r e n FSSC Nakamura, HSC
1968);
(Kazkin,
1983);
(3)
(2) The H op ele s s n e s s Scale for C hil d r e n
French,
Unis,
Esveldt-Dawson,
the Que st ionnaire
Animal Death
(Smilansky,
& Sherick,
for Examinat io n of Human and
1987);
(4) Three Piagetian
Conservation T a s k s and the Q u e s t i o n n a i r e Examination of Human and Animal Gentler,
(Scherer &
for the
Death QEHAD
(Goldschmid &
1968).
Pearson r correlations were c a l c ula te d between 4 components a nd age,
fear of death,
15
conversation,
hopelessness,
a n d experience with death.
Conservation
a n d experience w e r e seen as predictors of accurate death concepts
in sch oo l age children,
but their relationships
w i t h death concep ts were inversely related.
The
c o r r e lat io n c o e f f i c i e n t for c on ser va tio n was
.47 and for
experience it was
-.40
(N = 35, p < .01).
Cognitively
ma tu rin g c hi l d r e n m a y have difficulty und er standing death concepts when g i v e n an euphemistic explanation,
because
this information c ou nt ers to their d e v e l o p i n g conse rva ti on a b i l i t y
(Cotton & Range,
1990).
The
positiv e r e l a t i o n s h i p of conservation a b i l i t y and death concepts help d e t e r m i n e
that un der st a n d i n g death is more
related to ov er a l l cognitive d e v e lop men ta l ability than to age
(Cotton & Range,
1990).
This study r e v e a l e d through m u l t i p l e regression that si gnificant p r e d i c t o r s of death concepts were cognitive levels,
past experience,
were not a v a i l a b l e ) .
and fear of d e a t h
(statistics
Treatment implications
for children
de aling with d e a t h s hou l d reflect their cognitive deve lo pmental level an d past experience, age.
not just their
Providing e u p h e m i s t i c ex pl anations may only confuse
the child's c o n c e p t of death
(Cotton & Range,
1990).
Studies on Death E d u c a t i o n and Its Effects Children are society.
increas in gly exposed to death in our
Pro f e s s i o n a l literature indicates that there
16
are potential adverse effects of unresolved childhood grief
(Aspinall,
1996).
Aspinall
(1996)
felt that these
facts alone were enough to identify the need for death ed ucation in school curriculum,
Aspinall condu cte d a
literary review of what is known about children's understanding of death, research.
how children grieve,
an d relevant
The re searcher used current research to
develop an outline for a death education p r o g r a m that incorporated devel op men tal and theoretical principals on children's grieving process.
The goal was to provide
students with approp ria te information about the life cycle,
to identify a f fec ti ng issues assoc ia ted with
grief,
and to facilitate the development of effective
coping strategies for m a n a g i n g bereavement at the appropriate dev elo p m e n t a l levels. determined, research,
reactions all Aspinall
through personal observation and current
that a death e d uc ati on program may help
students to appreciate part of life.
life more and see it as a natural
Schools c ould also be able to manage
deaths and other crisis more effectively if they have developed a p r ev ent ati ve curr ic ulu m to collab or ate with a crisis plan.
By including de ath education in the
existing education curriculum,
such as math or reading,
children can und er sta nd and cope with death situations
17
and have a sense of t h r i v i n g in spite of a d v e r s i t y and unexpected d i s a p p o i n t m e n t s Guy
(1993)
(Aspinall,
1996).
m a i n t a i n e d through literature r e v i e w that
the amount of research that established the f o u n d a t i o n for using children's
l i t e ra tur e to examine e l e m e n t a r y -
aged children's c o n c e p t i o n s of death following a s t o r y presentation was limited.
In Guy's study a small group
(n = 31) of el e m e n t a r y ch il dre n were read, order,
three con textual
in a r a n d o m
stories that reflected real-l if e
situations adapted from children's literature ab ou t death. (1979)
Group d i s c u s s i o n followed each story and Kane's 10 components wer e used to structure the
discussion. separation,
These com p o n e n t s were realization, immobility,
dysfunctionality, appearance,
irrevocability,
universality,
causality,
insensitivity,
and personification.
The results of Guy 's
study revealed that c e r t a i n
patterns of Kane's stages of death conception wer e evident in his study sample.
The study r e c o m m e n d e d that
consideration be given to investigating the t h e r a p e u t i c benefits of death e d u c a t i o n and bibliotherapy w i t h young children and their c onc ep t u a l i z a t i o n of death
(Guy,
1993). Glass
(1991)
d e v e l o p e d a program to help s c h o o l age
students cope with and un d e r s t a n d death more effectively.
18
This p rogram co n s i s t e d of students v o l u n t a r i l y attending, for a period of six weeks, death,
a special interest course on
which was taught by counselors.
The child re n
involved in this p r o g r a m were given a pretest and a posttest to d e t erm in e the program's eff ectiveness. the posttest,
At
the expe rim ent al group scor ed 22% higher
than the control g r o u p on their un der st a n d i n g of death. This researcher d e v e l o p e d many suggestions and school counselors
for parents
to help c hi ld ren with their
understanding of death.
The m ai n s ugg estion was to
educate children on death,
so that they m a y be p r e p a r e d
to understand and cope with death as they exp erience Edgar and H o w a r d-H ami lt on
(1994)
it.
provide strong
literary support for the need for de ath ed uc a t i o n in elementary students by citing studies c om p l e t e d by Gor don & Klass(1979), (1992).
Baker,
Sedney & Gross
(1992),
They set out to design a p r o g r a m that w o uld help
children understand d e at h and process setting.
and Lewis
There were three goals
it in a nonc ri sis
for the program.
The
first was to give e a ch child inform at ion about death, such as terms to ex pr e s s
their feelings about death.
The
second goal was to c l a r i f y life and d e a t h values to reduce m i s c on cep ti ons about death.
The third goal was
allow the children to grieve losses that they m a y have already experienced,
and to help all c hil dr en be gin to
19
to
develop a p p r o p r i a t e g ri e v i n g behaviors Hamilton,
(Edgar & Howard-
1994).
The p r o g r a m d e s c r i b e d by Edgar and Howard- Ham il ton (1994)
was a n o n c r i s i s course in death a nd dy in g offered
to all children e n t e r i n g the 5*^^ grade in a large elementary school
in a un iv ersity city l o c a t e d in
southwest U nited States.
For a 10-year period,
approximately 1000 s tudents participated a n n u a l l y in the program.
S p e c i a l l y t r a in ed school p syc h i a t r i s t s
teachers taught the classes. m eeting 2 times a week.
and
The course l a s t e d 4 weeks,
A pre and p o s t - t e s t was given to
all children who a t t e n d e d the program.
T h i s was
to
determine the e f f e c t i v e n e s s of the course. Edgar and H o w a r d - H a m i l t o n reported that after 10 years with this p r o g r a m in place there has been both developmental and m e n t a l health benefits enrolled.
There was a 74% average in crease betwe en the
pre and post-test process,
for the children
on factual
life cycle,
Howard-Hamilton,
a n d mourning behavi or s
1994).
to the researchers
knowledge ab out the death (Edgar &
Long-term results were reported
t h r ou gh letters from st ud e n t s of
family members who w e r e later confronted w i t h a loss. These letters e x p r e s s e d that the in fo rma tio n the program provided helped the ch il d r e n to grieve a nd express feelings.
These re s e a r c h e r s felt that by c alm ly
20
their
presenting reality rather than imagination,
by he lpi ng
children learn words that express their experiences,
and
by helping them find supportive and dependable networks, children are able to deal with the reality of d eath (Edgar & Howard-Hamilton, 1991;
Gordon & Klass,
1994;
1979;
Guy,
Schonfeld and Kap pe lma n
Fulton,
1987; Glass,
1993; Mass,
(1990)
1984) .
believed that the
young child's immature un der st a n d i n g of the concepts related to death serves to elevate anxiety about death and interferes with successful adjustment to loss.
The
goal of their study was to de termine whether a schoolbased educational p ro g r a m could successfully pr omote the development of a more mat u r e concept of death in early elementary school-aged children.
The stages in
children's acquisition of concepts of death are identified in the study as irreversibility, (non-functionality), inevitability, (Schonfeld & Kappelman,
finality
and causality
1990) .
This study assumed that children acquire the concepts of death based on developmental stages. Inability to understand and process each of these concepts may cause a child to have difficulty p r o ce ed ing through an appropriate m o u r n i n g process.
These concepts
are compared with Piaget's stages of cognitive development.
Some argument is raised that concepts such
21
as life, birth and death are de v e l o p e d by natural pr oce ss and may not be affected by inter ve nti on Kappelman,
(Schonfeld &
1990) .
The study used a randomized sample to d e te rmi ne the effectiveness of a three-week, death educational program.
pro-active,
sc h o o l - b a s e d
It f ocused on the p r o m o t i o n
of the concepts of understanding death in 4-8 year old children. (Smilansky,
The Smilansky Death Con ce pt Questionnaire 1987)
was ad ministered to 184 children in an
individualized interview style as a pre and p o s t -t est evaluation.
The interventions c o n si ste d of
(a) a series
of six p resentations about concepts of death, educational presentations,
and
(b)
t eacher
(c) parent educational
presentation. The researchers'
school-based intervention was
found
to advance a child's understanding of death and rel a t e d concepts.
Sig nif ic ant gains were noted in total d e a t h
concept score,
the total score for human death,
score for animal death, age. 4.16
causality,
the total
inevitability a n d old
For the total death concept score the mean g a i n was (SD = 5.11,
p = 0.002).
In the total score for
human death the m e a n gain was 1.81
(SD =2.69,
p = 0.015).
The total score for animal death realized a mean g a i n of 2.35
(SD =3.28,
p =0.002).
The factor of causality
reported a mean gain of 0.86
22
(SD = 1.57,
p =0.0005).
The
factors of i n e v i t a b i l i t y and old age reporte d mean gains of 1.76
(SD =2.88,
p = 0.0002).
Ir re ve r s i b i l i t y and
finality did not diff er significantly.
The gain in total
death concept was seen as equal to the amount of cognitive con cep tu al development in one year without an intervention
(Schonfeld & Kappelman,
1990) .
The results
also indicate a "s tr ong correlation of age with the level of conceptual d e v e l o p m e n t related to d ea th correlation c o e f f ic ien t = 0.515, (Schonfeld & Kappelman,
in schools.
In this
N = 184,
p =0.0001)
(1995)
revealed the
1990).
A survey done by Jones et al interest of parents
(Pearson
in the development of death education survey 120 parents of fifth-graders
were asked if they w o u l d support a death education program.
A school c o un se lor who had repor te d an
increasing incidence of suicide and terminal illness in his district id e n t i f i e d the need for the program. survey d e t e rmi ne d that 71% of the pa ren ts
This
felt that a
death education p r o g r a m within the c u r r i c u l u m would be beneficial
for the de ve lop men t of their children.
parents cited violence,
teen suicide,
and alcohol related
m o tor vehicle accid ent s as primary reasons the program
(Jones et al.,
1995).
23
The
to implement
Su mmary and Im plications In summary,
for Study
a r e v i e w of the literature r ev e a l e d that
the study of the impact of de ath education on ch ildren's understanding of d ea th is increasing but cont inu es limited.
to be
There is m i n i m a l research on how p are n t s elect
to educate c h il dre n on death, death at all
or if they even address
{Schonfeld & Kappelman,
1990).
Schools are
the most logical site for de ath education to be cond uct ed since children are r eq u i r e d to attend, environment c o n du civ e to learning.
and it is an
It also p ro v i d e s a
non-threatening a t m o s p h e r e for an emotionally c ha r g e d issue such as death. Many of the studies
ad dressed the cog n i t i v e level of
children and how it af fects
their understanding of death.
Only a few studies r e s e a r c h e d the effects of a formal death education session.
Weaknesses of several of the
studies reviewed are the limitations of the sample, as size,
geographic re gio n and ethnic group.
limitations decrease
such
These
the generalizability of the studies.
A l tho ugh all of these studies contribute valua bl e information to the lit er atu re regarding the e f f e c t of death education on c h i ld ren 's understanding of death, research in this area shou ld be continued.
24
Hypothesis Following an educational session and group discussion concerning death,
childr en will have a better
understanding of death concepts than prior to the intervention,
as measured by scores of responses to the
Smilansky Death Concept Q u e st ion nai re
(Smilansky,
1987),
Definition of Terms The following are definitions that provided cl arity when reviewing this study. Death.
For the purpose of this study death is
d e fined as the permanent absence of life. Children,
Children in this study are in concrete
operational stage,
specifically 7-9 years olds in second
grade, Death E d u c a t i o n ,
This is a formal,
proactive
class roo m instruction about the life process and death, Piaget's developmental stages will be consulted and age appropriateness will be maintained. Understanding of d e a t h .
This understanding is the
process of conceptualizing death and progressing through the natural developmental stages of a specific age group.
25
CHA PT ER THREE METHODS
Research.Design A q uasi-experimental de sign was used to determine the impact of death education on children and their perception of death.
Data were collected using the
Smilansky Death Concept Questi on nai re The design was based on a partial Schonfeld and Kappelman
(1990)
purpose was to determine,
(Smilansky,
1987).
replication of the
study.
That study's
using a randomized control
trial, whether a school-based educational p r o gra m would successfully promote the develop me nt of a mor e mature concept of death in early ele men tar y school-aged children. Threats to the validity of the study are both internal and external.
The following internal threats
were identified and co nt rolled when possible.
The
children's past history will affect their responses to the questionnaire.
A child,
experience with death,
who has had more direct
may perceive death in a more
concrete manner than one who has no experience. Selection of the sample was limited due to the sensitive
26
nature surrounding death.
Death is a topic that is ofte n
stressful to discuss and causes a variety of e m o t i o n a l responses. A limitation to this s tud y was that it u s e d a convenience sample.
A c o n v e n i e n c e sample m a y be at yp i c a l
of the population stu di ed r e g a r d i n g important v a r i a b l e s bein g measured
(Polit & Hungler,
as a weakness in the study.
1995).
Also,
This was n o t e d
the c hil dr en m a y feel
compe ll ed to answer the qu e s t i o n s in a less than tr uth ful m a nne r to anticipate the cor re ct or an ticipated answer. To reduce this behavior the c h i l d r e n were f r e q u e n t l y reminded that "there are no wr o n g answers" and that all responses were confidential. The major threat to internal validity was instrumentation that was used.
the
This was r e l at ed to the
researcher's inexperience and subjectivity of dat a a n d in scoring of the tool used.
A t t e m p t s were made to e n s u r e
co ns ist enc y and reliability.
For consistency of scoring,
the researcher condu cte d all the interviews. scoring was completed,
W h e n the
a m a s t e r ' s prepared e l e m e n t a r y
educator listened to the ta pe d responses and al s o s c ore d the responses independently.
The researcher a nd the
educator then reviewed all resp ons es together, differences in scoring interpretation,
27
and then
reviewed
dete rmined a final score for each student.
This m e a ns of
scoring p r ov ide d an increased r e l i a b i l i t y to the study. One external threat to v a l i d i t y was that the children in this age group are e ag er to please the adult and could have been easily i nf l u e n c e d by the interviewer. The researcher is a regular v o l u n t e e r in the school and has a child who attends the school.
This relati on shi p
could have infl ue nce d the ch ild re n's answers to the study.
To avoid this,
the c h ild re n were e n c ou ra ged to
answer each quest ion honestly and not n e c e s s ar ily answer in a manner that they believe the r e s e a rch er w oul d like. A nother threat may have been the opinions and the reactions of the children's parents
about death.
T hese
could influence children's per c e p t i o n and responses of death.
An example would be if the parent would becom e
angry because of a personal loss, anger when understanding death.
the c h i l d sees o n l y A n o t h e r lim itation could
be within the school system and the cl a s s r o o m instructor's code of ethics.
These persons or systems
could direct the outcome of the ch ildren's the questionnaire.
responses to
Children are i n f l u e n c e d by their
adult mentors t hrough education,
religious,
or social
contacts. A final limitation or threat to val i d i t y arose
from
discomfort parents had in having their children e d u c a t e d
28
r e garding death in the school system.
Six parents
retur ned the demographic f or m but declined to have their child re n parti cip at e in the study.
All 6 forms r etu rn ed
c i te d that they felt this type of education was not appropr iat e in the classroom.
This may have also been an
influen ci ng factor for the 8 parents who did not re sp o n d to the questionnaire.
The re searcher made attempts
to
e d ucate parents on the im po rtance of the issue and t ried not to cause the parent dis c o m f o r t or undo pressure. Sample and Setting Before data were c o lle ct ed and the study was implemented,
the Grand Val l e y State University Human
Resea rch Review Committee
(telephone consent April
w r itt en consent June 1998,
see Appendix B) and the
e l e m en tar y school principal an d teachers i n vol ved approv ed the research plan.
1998,
(see A pp end ix C)
There were mi ni m a l
a n t i c i p a t e d risks identified in this study.
These are
iden ti fie d later in this chapter. The subjects for this s t ud y were children recruited f r om a rural elementary school.
The sampling me th o d for
this study was a n on- pr o b a b i l i t y convenience sample. T h ere was no attempt at r a n dom ize d selection of these classes.
A letter of explanation,
p er son al data questionnaire
consent,
and a
(see Appendix D, E, and F)
w er e sent home with each c hil d in the designated classes.
29
Second copies were sent to those who did not return the consents by the given deadline.
Follow-up calls were
made for those remaining outstanding consents. The target population for this study was children ages 7 to 9. (a)
Criteria for this study were as follows:
second grade,
speaking,
and
participate. were noted.
(b) experience with death,
(d) parents,
There were several sample bias issues that The study represents only Cau cas ian students A second bias is that
there was limited religious variation.
Methodist.
English
wh o agreed for the ch ild to
in traditional nuclear families.
religious
(c)
The p r i m a r y
faiths within this community were C a tho li c and Of the children in this study,
attending religious services.
89% reported
A third potential bias was
the weakness of a convenience sample.
Finally,
is limited to one geographic location.
the study
All of these
biases weak en the study by making it less gene ral iza bl e to the general population. With the exception of age,
the demogra phi c
chara ct eri st ics are s umm arized in Table 1. the participants
The age of
ranged from 6.92 years to 8.58 years
with a me an of 7.78 years con si ste d of 50% female
(SD = 0.525).
(n = 19)
30
and 50%
The p art ic ipa nts (n =19)
male.
Table 1 Chara cte ri sti cs of Subjects
(N=38)
Char ac ter ist ic
Frequency (n)
Percent (%)
Sex : Male Female Experience wi th Death: Mother Father G r a n dpa ren t Sibling Friend Other Pet None Attended a Funeral in last 3 years: Yes No Attendance at Religious Services: Wee kly At least monthly Oc c a s i o n a l l y Does not attend Level of Parental Educ at ion (n=76): Less than high school High school graduate Te c hni ca l/c oll eg e c ourses College graduate Some master's classes Master's/Ph.D. Marital Status: Never ma rri ed M a rried Wi dowed Divorced
31
19 19
50.0 50.0
0 2 14 1 16 11 21 5
0 5.3 36.8 2.6 42.1 28.9 55.3 13.2
22 16
57.9 42.1
15 6 13 4
39.5 15.8 34.2 10.5
3 16 18 25 7 7
7.9 42.1 47.4 65.8 18.4 18.4
1 37 0 0
2.6 97.4 0 0
Thirty-six
(94.7%)
children had e x p e r i e n c e d a death of a
person or pet in their nuclear or e x t e n d e d family. Twenty-two
(57.9%)
children had a t t e n d e d a funeral in the
last three years. weekly,
Fifteen
w hile o nly 4
religious services. parents
a t t e n d e d church
childr en never attended
Education levels of the children's
ran ged fr om less than high school
master's or Ph.D. parents
(10.5)
(39.5%)
97.4%
(n = 14).
(n = 37)
(n = 3 )
to a
Of all the children's
were married.
There were no
missing data on the demographic questionnaires. Instrument The S m i l a n s k y Death Concept Q u e s t i o n n a i r e was selected to e v al uat e children's p e r c e p t i o n of death.
The
Smilansky Death Questionnaire was d e s i g n e d and written by Sara Smilansky. obtained from Dr.
Permission to use the instrument was Smilansky
(see A p p e n d i x G ) , with the
help of M i r i a m Feinb er g of the Board of Jewish Education of Greater Washington,
who is a per so nal
friend of Dr.
Smilansky and serv ed as translator. The q u e s t i o n n a i r e is composed of two parts.
The
first 13 q u est io ns evaluate co n c e p t i o n of human death, and the s eco n d 13 questions deal w i t h conceptualization of animal death.
All the questions d i r e c t l y examine
children's u n d e r s t a n d i n g of death a n d differ only in
32
reference to human or animal 1987).
(see Appendix H)
(Smilansky,
The que st ionnaire was originally wri tte n in
Hebrew but was tr ans cr ibe d into an English man u a l in 1987.
Many influential researchers of childrens'
understanding of d eath have since used Smilansky's questionnaire as a b asis instruments Kappelman,
for developing their own
(Cotton & Range,
1990; Sc hoenfeld &
1990; Spe ece & Brent,
1992,
Speece & Brent,
1993) . Smilansky d e v e l o p e d the questionnaire b a s e d on conceptual categories re la ted to children's understanding of death:
irreversibility,
inevitability and old age
finality, (Smilansky,
causality, 1987).
To measure
a child's understanding of the life process,
the concept
of old age was introduced. Smilansky
(1987)
recommends that the questionnaire
be administered to eac h c hild in interviews lasting 10 to 20 minutes.
Scoring is based on quantity and the quality
of the answer the ch ild gives. be if a child were asked, in his grave,
An example of this would
"if a person dies and has been
can he be a living being again?"
scoring answer would be "no,
A high
a dead person can't come
alive again, because he is old." one of Smilansky's five concepts
Questions correspond to (previously stated)
and
are scored according to the correctness and explanation
33
of the answer.
The five concepts are scored i n d i v i d u a l l y
for both hu man and animals on a scale of 0 to 3. more complete the conceptualization, score.
The
the higher the
A score of 3 would b e g i v en if the c hi ld has
given a correct answer to the qu e s t i o n and also an appropriate explanation.
A score of 2 would be given for
two correct answers and one co rrect explanation.
A score
of 1 w ould be given if the c h i l d has answered one question correctly,
with one correct explanation.
A
score of 0 would be given if the child has a n s w e r e d both questions incorrectly or has
failed to answer,
or has
answered one question c or r e c t l y but its exp lan at ion is not correct
(see Appendix I ) .
T otal scores
for the
animal and human perception re la t e d to the concepts is 0 to 15, a total death concept score obtained by com bi nin g the two scores
(total of 30 points e a c h ) .
The da ta in
this study were analyzed for si gn ifi can t differences
in
children's understanding of d eat h before and a fter a session on death education. The Smilansky que sti on nai re has been used an d va lidated w it h 1242 Israeli children.
Construct v al idi ty
of the instrument was e s t a b l i s h e d utilizing a factor analysis that yielded 4 factors that together a c c oun ted for 67% of the variance.
The factors are ide nt ifi ed as
ir r e v er sib il ity of death,
f i n a l i t y of death,
34
c a u s a l i t y of
death,
i n e v i t a b i l i t y of death and o l d age
Kappelman,
1990).
(Schonfeld &
The r eliability of the q u e s t i o n n a i r e
has been e x a m i n e d by test-retest r e l i a bi li ty a n d i n t e r item consistency.
A random sample
(124)
of the same
Israeli ch i l d r e n were retested 4 w eeks later a f t e r original study.
the
The coefficient of c o r r e lat io n b e t w e e n
the total scores of these childre n on their first ex a m i n a t i o n and the total scores of their repeat exa m i n a t i o n was 0.84.
Since the c hi l d r e n could not
remember the an swers
to the 26 questions used in the
study 4 weeks prior,
a high c o e f f ici en t of c o r r e l a t i o n
indicates the e ff ect iveness of the Smil ans ky Death Co ncept Q u e s t i o n n a i r e For this study,
(Smilansky,
1987).
the researcher also e x a m i n e d
internal c o n s i s t e n c y of the Sm i l a n s k y Death Co n c e p t Q u e s t i o n n a i r e by cal cul at ing Cr onb ach 's alpha.
The
ov erall re l i a b i l i t y coefficient
for the i n s tru men t in the
pre-t es t and p o s t - t e s t was 0.62
(p = 0.000).
retest score (>.60)
(pretest and posttest)
This
test-
indicated st ro n g
s t ab il ity of me asu rem en t in the S m i la nsk y
instrument. I n te ri tem c ons is ten cy e x ami ne d to what e x t e n t the individual items a ff ec ted the general score.
Reliability
is b ased on i n t e r i t e m c onsistency as examin ed by Cr on bach's alpha,
w hic h is b a s e d on c orr el ati on be t w e e n
35
the individual items and the total conceptu ali za tio n of death.
The qu es ti o n n a i r e was scored separately for human
and animal death.
An alpha of
.77 was obtained,
indicating rel i a b i l i t y of the Sm i l a n s k y Death Concept Questionnaire
(Smilansky,
1987).
Procedure To obtain pe r m i s s i o n to conduct local e l e m en tar y school,
this study in a
the researcher made arrangements
to meet with the principal and two teachers whose classrooms w ou ld be involved.
The re searcher described
the study including the purpose, demographic i n f o rma ti on sheet, Questionnaire,
c onsent
form,
the S m i lan sky Death
the intervention,
and crisis intervention.
After making changes on the d e m o g ra phi c information sheet suggested by the school team,
the researcher was granted
permission to pro c e e d with the study.
It was agreed that
data c oll ection w o uld take no longer than two weeks of class time.
It was also agreed that the study would be
initiated by April 1998 and completed by June 1, 1998. The children's parents were as ked to complete a personal data
form an d sign a consent prior to their
child's p art ic i p a t i o n in the study.
This data provided
past history and general information about the children. The parents of the children in the s tu dy were notified in the class n ews letter when it was to take place.
36
Copies
of the signed consent
forms were kept on file at the
elementary school a nd the researcher kept a second copy. The Smilansky De at h Questionnaire was administered to each child in an in te r v i e w style, 10 to 20 minutes per child.
taking approximately
A script was developed and
delivered to each c h i l d for consistency that was based on the same death con ce pts as the pretest the intervention A p pendix L ) .
(see Appendix J) ,
(see A p p e n d i x K) and the posttest
Each c h i l d was interviewed both before and
after the int erv en tio n phase of the study. interviews
(see
(pretest a nd posttest)
The
were co n d u c t e d
privately outside of the classroom.
Care was taken not
to interrupt s c hed ule d class events or c u r r i c u l u m by reviewing daily sche du les with the teachers. The children's responses were re co rde d and scored with the explanation that is necessary to write their responses down and tape them so the re sea rc her would not overlook anything.
For consistency of scoring,
researcher conducted all interviews. completed,
the
Wh e n the tests were
a ma ste r' s pr ep a r e d ele mentary educator,
who
had been trained by the researcher to score the questionnaire,
li st e n e d to the taped responses and also
scored the responses
independently.
educator reviewed all responses differences in scoring,
The researcher and
together,
reviewed
and then dete rmi ne d a final score
37
for e ac h student. and its scoring,
Due to the su bjectivity of the tool this me ans of evaluation p r o v i d e d
i n c r ea sed reliability to the results of the study. The pretesting was c o m p l e t e d on each c h i l d in the study.
Within 1 to 2 days after the testing,
each class
was read the story The Fall of Freddy the L e a f ,
The
chil d r e n who did not p a r t i c i p a t e in the study were given extra computer time in the library.
This s t o ry presen ts
d e a th through a life cycle perspective.
A f t e r the story,
the childr en were asked as a group what the s to ry was about. such as,
They were en c o u r a g e d to use creative t h i n k i n g what are all po s s i b i l i t i e s in the story,
the s t o ry make them feel,
how did the cha r a c t e r s
and do they have experiences
how did feel,
similar to the story.
Five questions were a s k e d of the group to initia te c o n v e r s a t i o n about death concepts.
The c on c e p t s are the
basis of Smilanky's Death Questionnaire. are
(a)
finality of d eath
h a p p e n i n g to him?), to Freddie?),
(c)
T h e s e concepts
(Does Freddie know wh at
(b) c a u s a l i t y of death
i r r e v e r s i b i l i t y of death
is
(What h app ene d (Can Freddie
go b a c k to living in the tree after he has falle n o f f ? ) , (d)
inevitability of death
all of the leaves? get old?
Why?).
Why?),
(Does the same t h in g happe n to an d
(e) old age
The chi ldren's
(Which leaves
teachers were pr ese nt
d u ri n g the intervention to assist with any c h i l d r e n who
38
m a y have becom e distressed.
Q u e s tio ns pe r t a i n i n g to the
story were addressed without a n y religious or r e s e a r c h e r bias.
The purpose was to a l l o w the childr en open
d i s c us sio n time with their p eers to talk about their underst an din gs of death.
This
session was audio taped
for res earcher review so that a cc ura te accounts of the session could be obtained.
This in for ma tio n c o ul d be
used for review of the ch ildren's responses or to su ppo rt conti nu ed research on death education,
bibliotherapy,
and
group discussion. Af ter the group in ter ve n t i o n was comp le ted a p o s t test inte rvi ew was conducted w it h i n the following days.
1 to 2
The posttest was scored in the same fashion as the
pretest.
The second rater also scored the audi ota pe d
interviews,
and final scores were ag ain agreed upon by
conferencing.
All audiotapes were era s e d after the d at a
were analyzed. Ch il dre n whose parents di d not want them to pa r t ic ipa te in the study
(n = 14)
were a llowed to
pa r t ic ipa te in a separate story session. was read was The New Three P i g s .
The s tory that
The re sea rch er also
spent individual time with those c h il dre n reading from their d aily reader.
These c h i l d r e n were given extra
compu te r time while the study c hi l d r e n were p a r t i c i p a t i n g in the intervention.
39
CHAPTER 4 RESULTS
The purpose of this research study was to determine if death educa tio n has an impact on children's understanding of death.
This chapter includes a summary
of findings in terms of the research question,
"What
effect does an e d u c a t ion al session that includes a story addressing death and subsequent peer group discussions have on school age children's u n d e r sta ndi ng of death?" Data were ana lyz ed using the software Statistical for the Social Sciences
(SPSS)
for Windows.
Package
An alpha of
.05 was used to d e te rmi ne significance of statistical coefficients. A total of 52 consent forms and d emo gra ph ic questionnaires w ere distr ib ute d to a rural, class.
Of those,
second grade
44 questionnaires were returned within
the 2-week time frame for a return rate of 85%.
Thirty-
eight parents a gre ed to have their chi ld ren participate in the study and 6 declined.
All 6 sets of parents
stated that the reason for not p a r t i c i p a t i n g was that they felt that the ch ildren should have death education at home or in church.
There was one case of attrition
40
from the study. This c hild participated in the pretest and the intervention.
However,
the c h i l d was absent for
the posttest evaluation. Table 2 Summary of Smilansky Death Concept Scores SD
Mean
Conceptualization of Death Human Death Concept Pretest
12.76
1.22
Posttest
14.35
0.75
Pretest
12 .90
1.20
Posttest
14.46
0.84
Pretest
25 .66
2.13
Posttest
28.81
1.41
Animal Death Concept
Total Death Concept
Scores in points
for the Smilansky D e a t h Concept
Questionnaire were subdivided into human d e a t h concept - 15),
animal death concept
concept
(0 - 30).
(0 - 15),
(M = 12.76,
pretest and 12 to 15
(M =14.35,
to 14
SD = 1.22)
on the
SD = 0.753)
on the
Scores for the animal concept r a n g e d from 10
(M = 1 2 . 9 ,
(M =14.36,
and total death
Scores for the human d e a t h concept
ranged from 11 to 15
posttest.
(0
SD = 1.20)
SD = 0.836)
for the p r e t e s t and 12 to 15
for the posttest.
concept scores ranged from 21 to 29
41
Total death
(M = 25.66,
SD =
2.134) 1.41)
for the pretest a n d 25 to 30 for the posttest.
(M = 28.81,
SD =
See T a ble 2 for summaries of
these test scores. In this study pair ed t-tests were used to asse ss the overall intervention ef fe c t on the total scores death,
scores for animal death,
de ath concept.
for human
and scores for total
The d i f f e r e n c e s between the p r e t e s t and
p os tte st scores were used to determine if there was an improvement in u nde rs t a n d i n g d e a t h in the children.
The
postt es t scores in this s t u d y were significantly higher than the pretest scores i n d i c a t i n g an increased un derstanding of death f o l l o w i n g the in tervention
(see
Table 3). T a ble
3
C o mparisons of Pre- and Po st tes t Death Concept Scores
Concepts
Pretest
posttest df
M
SD
M
SD
T
Total Death Concept
25.68
2.16
28.81
1.41
-11.20
36
.000
Human Death Concept
12 .81
1.19
14.35
.753
-8.36
36
.000
Ani mal
12.86
1.20
14.46
.836
-9.33
36
.000
Death Concept
T-tests were p e r f o r m e d to determine if ch i l d r e n with va rying demographic b a c k g r o u n d s differed in their un derstanding of death.
T h e r e were no si gnificant
42
P
relationships between any of the demographic vari abl es and the Sm ila ns ky Death Con ce p t scores
(see Table 4) .
Table 4 C o mp ar iso n of Demographics a nd Death Concept Scores Demographics
Group of Ch il d re n
Gende r
Pretest
t-test
df
P
.53
36
.602
Posttest
1.07
35
.290
Pretest
1.26
36
.215
.69
35
.4 92
-.54
36
.594
Posttest
.01
35
.995
Pretest
.46
36
.650
Posttest
.78
35
.440
A t t e n d e d a funeral
Pretest
.54
36
.594
in last 3 years
Posttest
1.42
35
.163
A t t e n d e d religious
Pretest
-.27
36
.786
services
Posttest
.41
35
. 683
Death Experience Pet
Posttest Friend
Other
Pretest
Parent education level v a r i e d for each child.
The
q u es ti onn air e was not s pec ifi c in its directions re ga rdi ng who should respond to its questions. it cannot be dete rmi ne d w h e th er mothers' edu c at io n was reported. (ANOVA)
However,
T h e r ef or e
or fathers'
an analysis of v a r ia nc e
was used to d et er min e if there were s i gn if ica nt
43
differences in pretest and posttest scores with di fferent levels of parental education.
The levels of education
were collap se d into high school and less, school,
and college and above.
technical
Each of these groups were
divided into parent education A and parent education B as listed on the demographic form and further evaluated b y ANOVA.
No two groups were sign ifi ca ntl y different wit h
alpha de si gn ate d as
.05.
Other Findings of Interest One point of interest noted when interviewing these children was that only a few m e n t i o n e d the death of their classmate that occurred the previous year. of the crisis,
the children were r ep eat ed ly exposed to
crisis intervention, conducted,
At the time
several fund raising events were
and ma ny memorials were held.
Although these
children were extensively exposed to de ath issues,
it was
not significant enough for the children to recall duri ng this study. Another area of interest had to do with the children discussing death with their parents.
Th ey were
encouraged to discuss the pretest and intervention with their parents.
During the posttest o nl y a few me nt io ne d
that they had disc uss ed death issues with their parents. The researcher was unable to determine if the children in the study dis cu ss ed death issues with their parents.
44
The
researcher was also unable to d e te rm in e if discussing death issues with their parents e f f e c t e d the children's understanding of death.
Further re s e a r c h is necessary to
determine if d i s c u s s i n g death with t h e i r parents has any effect on chil dre n' s understanding of death. The children in this study had v a r i e d experiences with death as r e p o r t e d by their parents.
Some of the
children ide ntified personal e xpe rie nc es wi t h death, others did not.
T h e r e were no q u e s ti on s
yet
that asked the
children about pe r s o n a l death experiences.
The children
may have shared di f f e r e n t experiences w i t h the researcher,
that m a y have been more si g n i f i c a n t to them,
than the death ex pe ri en c es identified b y their parents. In identifying these personal death experiences, children may have rep o rt ed a different understanding of death.
45
level of
the
CHAPTER 5 DISC US SIO N A N D IMPLICATIONS
The purpose of this
s tu dy was to de termine
if de ath
education in ele mentary age children affect ed their unde rs tan di ng of death.
Pa ir e d t-tests and A N O V A
analysis were used to e v a l u a t e
relationships b e t w e e n
demogra ph ic data and S m i l a n s k y Death Concept test scores. This chapter includes a r e vi ew of the de mo gr ap h ic s of the sample,
a discussion of findings,
nursing,
and re co mm end at ion s
implications
for
for research and
im pl ementation of a death ed uc at io n pro gra m in e x i s t i n g school curriculum. Discussion of Findings Results of this s t ud y suggest that a de ath e d u c at io n p r og ra m or session can in c r e a s e a child's u n d e r s t a n d i n g of death.
After a death e d u c a t i o n intervention,
posttest revealed s i g n if ic a nt
the
improvement in
understa nd ing compared to the pretest scores.
T he se
study results parallel the results by Schon fe ld and Kappelman
(1990)
who found sim ila r correlation w i t h
46
chi l dr en 's understanding of d e at h after a death e d u c at io n intervention p = 0.0001).
(Pearson c o r r e l a t i o n coefficient = 0.515, The Schonfeld and Kappelman study a lso
rep o rt ed a strong cor re lat ion of age with the level of con c ep tu al development was not seen in this study. findings
The
regarding death e d u c a t i o n and children's
u n d e r s t a n d i n g of death agree wi t h the Speece and Brent. (1984)
belief:
Children's exp er ie nc es with death,
i n c lu di ng their experiences w i th actual death as well as what th ey have been told ab out death,
are p r o b a b l y
crucial to their u nd ers ta ndi ng of death S c h o nf el d & Kappelman,
(as ci ted in
1990).
The children's average scores on the S mi l a n s k y Death Q u e s t i o n n a i r e in this study wer e higher than those r e c or de d in the Smilansky
(1987)
study.
The S m i l an sk y
st ud y r e p or t ed pretest and p o s tt es t mean scores of 22.6 and 23.5
respectively.
This s tu dy reported me ans
25.66 for the pretest and 28.81 difference
of
for the posttest.
One
in the two studies was that the Sm il a nsk y's
st ud y did have a wider range of age than this st udy 12 years),
which could be one explanation for the
m e a n scores.
Schonfeld and K a p p e l m a n
(1990)
(4 -
lower
rep or te d
gains sim il ar to those of this st udy in the p r e t e s t and p o s t t e s t m e an scores.
47
An explan ati on for the hi gh er deat h concept scores could be that these children as a gr ou p received grief crisis counseling 1 year prior to this study. counseling was part of a crisis
The
i n t e r ve n ti on after three
local children were killed in a m o t o r vehicle accident. Alt hough only a few children in this gro up mentioned the death of their classmate during the interviews,
the
experience with de a th could have i n f l u e n c e d how these children u nd ers ta nd and process death.
Four children's
de mographic forms reported no e x p e r i e n c e with a death, yet each of these 4 children were i n v o l v e d in the previous year's crisis intervention.
This could have
indicated that even the parents of these children did not see these deaths as significant in their child's life or that it was an issue that they had a l r ea dy processed. Guy
(1993)
also used b i b l i o t h e r a p y as an
intervention in his study of c hi ld re n's understanding of death.
Guy's goal was to support the idea that
bib lio the ra py could encourage c h i l d r e n to explore and express their feelings on death.
Li ke this study,
he
used a pretest and posttest to e v a lu at e the children. His study found that after ch il dr en l is te ne d to a story on death they had a better u n d e r s t a n d i n g of death related issues
(no statistics a v a i l a b l e ) . Th e s e
similar to the results of this study.
48
results are He also felt that
the children were be tt e r able to express their feelings about death after the bibliotherapy. There were no significant relationships among any of the demographic variables and the Sm ila ns ky Death Concept Scores in this study.
As previously mentioned,
sample size m ay have contributed to this.
the small
A replication
of this study with a larger sample m i gh t reveal that the demographics are r e la te d to children's understandings of death. Death ed uc at ion through bib li ot he ra py and group discussion in this
study provided an in creased
understanding of d e a t h to the study group.
It is not
known if this in cre as ed understanding was based on knowledge or on the actual understanding of death. Further research needs
to be conducted in this area.
Factors influencing the increased u n d e rs ta nd in g of death could have been due to the children's discussions of death with their pare nts after being s ti mul at ed by the pretest and intervention.
Some of the children reported
that they did talk to their parents about death.
These
children were c on fid en t in their responses to the posttest.
Overall the children were more open to
discussing death issues in the posttes t than in the pretest.
It was the researcher's goal to provide the
children in the s tu dy the permission to discuss death.
49
the terms to use, life cycle. goals,
and to develop their k n o w l e d g e of the
C h i l dr en in this study did m e e t some of the
however more r e s e ar ch is nee ded to f u r t h e r
de termine this. Death education was an influencing fa ct o r in this study group's in cr ea se d un d er st a nd in g of death. pro vi de d the childre n of this group comf or t
in dis cussing
d ea th as evidenced by the increased po s t t e s t the Smilansky Death Con ce pt Questionnaire.
It
score s on S ome children
also discussed d eat h issues with their p a r e n t s be in g encouraged by the st udy intervention.
af ter
M a n y of the
ch ild ren were even w i l l i n g to be i nvo lv ed in the group di scussion after the posttest.
Death e d u c a t i o n m a y not
be a vital part of the school curriculum,
b ut
it
encourages the c hi ld to seek out more i nfo rma ti on.
Their
parents can then c o n t i n u e the colla bo rat iv e p r o c e s s
of
he lp in g their ch il dre n un de rs t an d death. Although the scores did not reflect it,
m a n y of the
ch ild ren dicussed d e at h w i t h religious af fi li at io n.
This
m a y have had some e f fe ct on the increa se d m e a n scores. The children with m o r e
religious ba ck g r o u n d m a y have had
a more concrete u n d e r s t a n d i n g of death.
M or e r e s e a r c h is
neede d with a larger sampl e and more s p ec if ic questi ons to determine if r e l ig i on plays an active role in children's un der s ta nd in g of death.
50
A d d i ti on al ly ,
the
Sm i l a n s k y Death Concept Qu est ionnaire,
and oth er
instru me nts like it wou ld ne e d to be e va lua te d for their ef fe cti ve nes s in eval uat in g c h i l d r e n with strong relig io us backgrounds before these instruments s ho ul d be used in these studies. The death education i n t e r v e n t i o n and S m i l a n s k y Death Co n ce pt Questionnaire were well tolerated.
Mos t of the
ch il dr en verbalized that the y e n jo ye d the study.
Neither
teachers nor children's p ar en ts
reported a dv ers e e f f e c t s .
M a n y parents expressed int er est
in obtaining the study
results
from the el em en tar y sc hoo l' s office wh e n they
b ec ame available. R e la ti on sh ip to Conceptual
Fra me wo rk
Chi ld ren in Piaget's d e v e l o p m e n t a l stage of concrete op e ra ti on al thought are curi ous a n d seek out furt her information, (Aspinall,
especially wh en s t i m ul at ed with ed u c a t i o n
1996).
Death e d u c a t i o n is only the beg in n in g
of de ve lop in g children's u n d e r s t a n d i n g of death. this transition,
During
children se ek out more i n f o r ma ti on from
their parents and mentors
(Aspinall,
1996).
The
e d u ca ti on process then b ec om es a co llaborative process. This process assists the c h i l d r e n (Labinowicz,
to reach e q u i l i b r i u m
1980) .
According to Piaget,
c h i l d r e n in the con cr e te
o pe r a t i o n a l stage see issues as co ncrete and do not
51
always identif y with concepts that are necessary to understand de ath as a complex is sue 1992).
Smi la ns ky
finality,
(1987)
(Speece and Brent,
ide nti fi ed the concepts of
non-reversibility,
causality,
inevitability,
and old age as necessary for ch il dr en to understand death.
Ch ild re n have to process these concepts by
adapting and org ani zi ng them to their environment (schema).
T h ey then have to i n c or po ra te death experience
or education
(assimilation)
and m o d i fy it
(accommodation)
into their ex i s t i n g lifestyle a nd environment. process provides balance
(equilibrium)
This
to the child's
life. Although the children in this st udy are in Piaget's concrete ope rat io nal stage,
their un de rst an din g of death
as a complex issue was well developed. (1994)
Speece and Brent
felt that children develop their adult concept by
age 8, which m a y explain why the childr en in this study scored high on the Smilansky Death Co nce pt Questionnaire. Greater than 97.4% of these c h i ld r en had experienced a death of a p e r so n in their nuc le ar or extend ed family. This group of children also id e nt if i ed de at h as inevitable.
All of these childre n i de nti fi ed death as a
natural process of life.
52
Limitations of the St udy This study r e c r u i t e d a small, convenience sample
n o n - ra nd om iz ed
fro m a small rural e l e m e n t a r y school.
Small samples and indiv idu al data c o l le ct io n settings are less representative of the population be ing stu die d and limit the ability to generalize the findings Hungler,
(Polit &
1995).
A convenience sample was used for this study. According to Polit and Hungler randomized co nv en ie nc e available subjects, population.
(1995)
limitati on s
to n on
sampling is due to the use of
who m a y not be typical of the study
Using a sample with only Caucasian,
traditional nu cle ar geographic valences,
families,
no racial differences,
no
or religious var ia ti on also m a y
increase the risk of bias and make the s tu dy less generalizable. Another lim it at io n to this study was that education level varied for each parent,
but the q ue st i o n n a i r e was
not specific in its di rections regarding who should respond to its questions.
An appropriate r evi si on of
that instrument w o u l d ask for the parent to be specifically i d e nt if ie d as mother,
father,
grandparent,
or other caretaker to acc ura te ly identi fy a rel ationship between parent e d u c a t i o n and children's u n d e r s t a n d i n g of death.
53
A weakness to this and Kappelman
(1990),
study,
also shared b y S ch onf el d
is that the educational
interve nt ion may have
tau g ht the children ap pr op ri a te
responses and not p r o m o t e d an increased u n d e r st an di ng of death.
This could be a v o i d e d by having di ff er en t
in di vid ua ls deli ve r the in te rve nti on and co nd u ct interviews,
with d i r e c t i o n s
the
to avoid using la ng ua ge
from
the qu est ionnaire in the intervention. R e c o m m en da ti on s Based on i n f o r m a t i o n gat he re d in this s t ud y and c o l l e c t e d in the l ite rat ur e,
the following
recommen da tio ns are offered. R e s ea rc h The following r e c o m m e n d a t i o n s are o f fe re d for nu r si ng research.
R e s e a r c h studies are n e ed ed to clarify
the most effective m e a n s of de ath education in children. Future recomme nd ati ons
for research would be to conduct
st udies using a la rg e r and m or e de mo gr ap h ic al ly varie d sample.
This w ou ld m a k e
the general public. f r om a single,
the study more g e n e r a l i z a b l e to
T h e c h i l d r e n in this s tu dy were drawn
r e l a t i v e l y homogenous
wh it e middle class
families.
rural c o m m u n i t y of
Because of this,
a second
re c om men da tio n is to a l s o e x te nd the age range to both yo un ge r and older c h i l d r e n to explore more tr an si ti on
54
periods be tween levels of un de r s t a n d i n g Brent,
(Speece and
1992) .
In future studies,
a m ore c o m p l e x demographic
e v a lu at io n of the parents a nd their views on death could give mo re insight to children's un de rs tan di ng of death. C h i l d r e n learn and develop concep ts and mentors.
from their parents
If a parent were h a v in g difficulty
u n d e r s t a n d i n g death concepts, s tr ugg le with death concepts.
then a child may also Not only does the parent
need the coping skills to e f f e c t i v e l y process death concepts,
but also they need to c o n v e y those skills to
their children. impor ta nt receive
If they are unable to do so, it is
that they know where to find the resources to
those skills for the mse lve s and their children.
Nu rs in g could serve as an advoca te help t he m find the education,
for these people to
resources,
and help that
they m ig ht require. A l t ho ug h this study did not indicat e religion as a factor in the children's u n d e r s t a n d i n g of death, in this area is needed. study re fer re d to "God,
researc h
Ma ny of the children in this going to Heaven,
or a better
place" du ri ng the interview pro ces s with the Smilansky (1987)
questionnaire.
In a large sample,
religious
ba c k g r o u n d mi ght be shown to have a significant
55
relationship with the children's un der st a n di ng of death and with death education. Another re commendation for research is concerned with an alteration of the intervention phase of the study.
The children of this study seemed to identify
with the animal section of the Sm il ans ky questionnaire. They showed more comfort when ans we ri ng the animal section of the questionnaire.
This finding suggests that
children may be helped to und erstand death if a story that involved animals or in corporated animals were used as a part of a death education curriculum. Extending the time frame of the study to 8 weeks is recommended.
By increasing the time from which the
intervention and the posttest are conducted, reduce testing effect.
it may
The children wo uld have time to
develop their un der standing with help from other resources,
such as parents,
mentors,
or clergy.
It would
also decrease the chances of children simply reciting what they learned duri ng the interve nt ion or death education phase. A final rec ommendation would be to extend the study to a longitudinal one. at a later date,
By evaluating these same children
the researcher could deter min e if the
death education se ssion was effective, were sustained.
and if its effects
If these effects were sustained,
56
it
w o uld provide ad ditional s u p po rt
for developing a d e a t h
edu c at io n program for s c ho ol age children. N u r si ng Education Nurses can play a p r i m a r y role in an org an iz ed d ea th edu c at io n program.
N u r s i n g has the knowledge base in
children's cognitive d e v e l o p m e n t a l
levels,
wh ol is ti c view of carin g for children, type of program.
including a
to develop this
The re su lt s of this study indicate that
a death education p r o g r a m w o u l d assist children in understanding death. promote,
develop,
N u r s i n g possesses the e xp ert is e
and i m p l e m e n t a preventative p r o g r a m in
a current school's curricul um. be used to consult with scho ol d e ath issues,
to
This expertise also c o u ld systems,
advise par e nt s
on
and i n c o rp or a te d eat h education into cri sis
intervention programs. For any education p r o g r a m involving children to be successful, ad vantage
the parents h a ve to be convinced there is an
for their children.
the parents in this pr oc e ss ed uc ato r and the parent needs of the children. ed ucational program.
It is important to inv ol ve
of death education.
The
can col la boratively focus on the D e a t h ed ucation is a m u l t i - f o c u s
It is important to provide c o n c r e t e
informat io n to children t h r o u g h the school system and religious beliefs in church.
The parents can use the
co mb ina ti on of the school e d u c a t i o n and the religious
57
beli e fs
to pro vid e the children w i t h the skills to better
u n d e r s t a n d death and its concepts. The r ese arc h is limited on the children's u n d e r s t a n d i n g of death and death edu ca ti on 1996).
(Aspinall,
M an y authors have t h e o ri ze d as to what would be
an a p p r o p r i a t e curriculum for ch i l d r e n on death education. ideal
This data and the n u r s i n g process,
fr am ew or k to assess,
develop,
provide an
implement and
e v a lu at e a de ath education p r o g r a m for children.
Nurses
c ou ld s p e c i f i c a l l y design a c u r r i c u l u m focusing on the de v e l o p m e n t a l and situational needs of children.
The
c u r r i c u l u m co ul d then be i m p l em en te d and evaluated for its effectiv en ess .
The nursing p r o c e s s helps to
e s t a b l i s h the effectiveness of a de ath education p r o g r a m in school age children. N u r s i n g Practice Nurs es
in a practice setting have a unique
o p p o r t u n i t y to evaluate a vari et y of children. pare n ts
Both
and childr en establish t r u s t i n g relationships
wi t h nurses.
Through this relationship,
nurses can take
time to eva l ua te and discuss d e a th educa ti on with children,
the children's un d er s t a n d i n g of death,
views of their parents.
and the
Many times childr en present
vague p h y s ic al symptoms when they are emotionally di s t r e s s e d or are having di f f i c u l t y copin g with a loss.
58
The advanced pr a c t i c e nurse
(APN)
can e v al ua te the child
holistically and provide counseling to the child as appropriate.
The AP N can also prov ide g u i da nc e to the
parent of a ch ild who may have e x p e r i e n c e d a death or who has questions about death.
Nursing also has the
expertise to eva lu at e children on their un derstanding of death and provi de education to chi ldr en and parents on death related issues as appropriate. Nursing can deve lo p public aware nes s about death education and its effects on children's un derstanding of death utilizing various community resources.
If a
practicing AP N identifies a need in a community,
such as
a community with high incidences of ca n c e r or suicide, presentations to parents on death e d u c a t i o n and children could be beneficial.
These p re se nt ati ons co ul d be given
in schools,
or at conferences.
churches,
Whe n parents
are informed they m a y be more willing to a pp rov e and utilize a death educa tio n progr am in the school curriculum. Summary and C o n cl us io n In conclusion,
for children to u n d e r s t a n d death in a
manner that pr ovides
them with comfort at their
developmental levels,
more research a nd de at h education
programs are needed.
Nursing can b r i d g e the gap between
59
what is known through re sea rc h and what is actually being prac ti ced in a school system's curriculum. Facing loss is a real ity of life,
and helping
children understand this reality is not an easy task. C hil dre n possess some of the same feelings adults have, but lack the resources and cognitive de ve lop men t to unde rs tan d them.
Chi ld r en can be hel ped to develop these
skills through education. death,
By educating children about
they m ay have a bette r understanding of the death
process, feelings.
terms used,
a nd more awareness of their
This may p o s s i b l y help childre n be more
pre p ar ed for a loss.
Incorporating a death education
pr og ra m into an existi ng curri cul um w o u l d be a positive step for any school sys te m to consider.
60
A PP EN DI CE S
APPENDIX A Consent to Use Piaget Con ceptual
Framework
09/03/9»
THU 14:53 FAX 314 523 496»
Gbooi
HOSBY LIBRARY
APPENDIX A 901 L _ M a. M cNbmi 49101 PIMm ;C1M 92«742
Fmcei&W"*»»»
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Pdt
Pnaaw Diana Schramm
Page
314423496*
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SeotoRtoerl 1998
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toagaas 1
Nat
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PBt TWs is a raquest fcr Vie pemiiisiaa to u u h my Nunkig Masters ttiests ttw oonoepiual ftanewortc by Piaget ftoni your oompanies book Med ‘Nursing Car# of Intonts and Chfldtan*. authored by uiefle ViVtaley and Donna V\fang. eopy wrta 1V79. Page tG8. Phase f u toe penmsian atotement to fax manber 616>787-488S. alto; Diana Schramm Thank you toryour help.
Diana Schramm
Mosby. Inc. _
11630 Wedline InduitooJ Onva St.Lou«.MO 63146
Permissions Coortf noW
Ubrary Senricts and Permissions
t*d
aNIM33NI3N3 'toOO'O AbTUS U d 6 E :ie
61
0S> E0
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AP PEN DI X B Human Subjects Review
APPENDIX B
G r a n d \à lle y S t a t e O srtV E R S T T Y I CAMPUS DRIVE • AUJENOALE.MICHIGAN 49401-9403 • 6 I6 /8 9 S -6 6 II
June 24, 1998
Diana Schramm 901 Boynton Ave. SE Ada, MI 49301 Dear Diana: The Human Research Review Committee o f Grand Valley State University is charged to examine proposals with respect to protection of human subjects. The Committee has considered your proposal, "The Concept o f Death Education on Children's Understanding o f Death”, and is satisfied that you have complied with the intent of the regulations published in the Federal Register 46 (16): 8386-8392, January 26, 1981. Sincerely,
Robert Hendersen, Chair Human Research Review Committee
62
APPENDIX C E l e m e n t a r y School Ap proval
APPENDIX C
AREA SCHOOLS i. ELEMF.NTA«V SCHOOL 12675 Foreman Road.
Phone r
- Fax(f
William A. Principal
..,
A p ril 1,1998
Maureen
Assistant Principal
Diana Schramm 901 Boynton Ada, MI 49301 Dear Diana, I am writing this letter to give you permission to conduct the student survey a t Cherry Creek Elementary regarding death. You have indicated that you will be working with two 2nd grade classrooms; Mr. ' & Mrs. I have reviewed all materials and the permission slips that will be used. Procedures seem to be in good order. Sincerely, '■
BilU
63
APPENDIX D Letter to the parents
APPENDIX D M a y 12,
Dear Parent
1998
(s ) :
My name is Diana S c hr am m and I am a gr ad u at e student at Grand Va ll e y State University in the fami ly nurse practitioner program. In order to fulfill the requirements for a Master's degree in Nursing, I am conducting a res ea rc h study with second gr aders of your child's school on children's un de rst an din g of death and the effects of d eat h education. The se co n d grade teachers, Mrs. D ., Mr. G. and the pr in ci pa l Mr. M ., have given their su pport and approval to p r oc ee d with this study. I sel ec t ed these children be cau se of their c o m m o n loss of a fellow student in 1996, their age and accessibility. I beli ev e that these chi ldr en will pr ove to have an hone st interest in the subject and will be willing to participate. I also feel that these c h i l dr en know me and will not feel threatened by the questions asked in the study. I hope that you will allow your child to p ar t i c i p a t e in this study. It is ine vitable that children are ex po s ed to death. Children will ne ed to accept and und er st an d death as a natural process of life. Learning about d e a th m ay help children to be bet te r prepared to cope wit h their emotions and d e c r e a s e their fears about d e a t h when t hey do experience the loss of a loved one. For this study, I will ask you to read and sign a c o n s e n t form and comple te a personal data sheet. I will then meet with the chi ld r en separately and ask t h em 26 questions about death. An example wo uld be: Can a d e ad animal drink or eat? This pre-test will ev al uat e your child's u n d e r s t a n d i n g of death. The class will then be read the story "The Fall of Freddy the Lea f, "w hi ch is a story about the lifecycle. They will be a s k e d in class about the m e a n i n g of the story. Five quest io ns will be asked to the g ro up to initiate co nve rs a ti on about de ath concepts. T he se concepts are (a) finality of death (Does Freddie know what is happening to him?), (b) ca u s a l i t y of death (What ha p p e n e d to Freddie?) , (c) i r r e v e r s i b i l i t y of death (Can Freddie go back to living in the tree a f te r he
64
has fallen o f f ? ) , (d) inevitability of d e a t h (Does the same thing happ en to all the leaves? W h y ? ) , and (e) old age (Which leaves get old? Why?), Q u e s t i o n s related di r e c t l y to the s tory will be a d d res se d w ith ou t religious or res earcher opinion. The children w i l l again be asked the same 26 q u es ti ons individually. A l l information will be kept c onf id e n t i a l and only be used for this study. A small toy will be given to the childre n as a token of my appreciation. The individual interviews will be audio taped for accuracy. These tapes will be e ras e d after the study is completed. If you choose to have your child not p a r t i c i p a t e in this study, I will be r eading a story (The N e w Three Pigs) to your child for pl ea s u r e purposes only. T h e y will have li brary time dur i n g the reading of "The Fall of Freddie the Leaf." I do not want these c h i l d r e n to feel left out, so I also pl an to spend individual time with each ch ild reading f r o m their accelerated r e a d i n g books if they do not pa r t i c i p a t e in the study. T h e y will also receive a small toy as token of m y appreciation. In m y experience, children of this age g r ou p have w o n d e r f u l l y o p t i m i s t i c views. They m a y not o f t en have the o p p o r tu ni ty to discuss issues, such as death, but are ea ger to express their ideas. The p a r t i c i p a t i o n of your ch ild in this s tud y wo uld be greatly apprec ia ted . Please complete the data collection form and the consent form and return it by M a y 18, 1998 to your c h i l d ' s teacher. If you have any quest ion s you may co nt a c t me at the number b e l ow or Dr. Paul Huizenga at G r a n d V a l l e y State University, 616-895-2472. I am also w i l l i n g to meet with you if would like to receive further i n f o r m a t i o n on the study. Please return the questionnaire regardless of your decision, so that I can place your c hi ld in the appr op ria te group. T h a n k you for your time and c ons id eration Sincerely,
Diana S c h r a m m BSN, RN 901 B o y n t o n Ave S.E. Ada, MI 49301 616-682-9742
65
APPENDIX E Consent
Forms
AP P E N D I X E CO N S E N T
FORM
I understand that this is a study about children's understanding of death and the effect of death e d u c a t i o n on their understanding. There will be a p p r o x i m a t e l y 35 children in this study I understand that: 1. participation in this study will involve a p r e test assessing m y child's understanding of death. 2. the book "The Fall of Freddy the Leaf" wil l be read to all of the children in the study. There will be a copy in the school office. 3. a post-test will be given to my child to a gain assess my child's understanding of death a fter being read a story involving death. A c o p y of questionnaire will also be kept in the office. 4. my child has been s e lec ted for p a r t i c i p a t i o n in this study due to their age group, accessibility, and their common loss of a cl a s s m a t e . 5. it is not expec ted that this study will lead to any physical risk to m y child. There wil l be minimal emotional risk and it could help h im/her have a better un der st a n d i n g of death. 6. the information that m y child provides will remain strictly con fidential and the data will be coded so that identification will not be possible. This inform ati on will be au dio taped. At the end of this study the tapes will be erased. 7. if my child exhibits any signs of dis tr ess or becomes upset the study will be discontinued, he/she will be c o n s o l e d as needed and the parents will be notified. 8. a summary of the results will be made a v a i l a b l e for the group I acknowledge that: "I have been given the opportunity to ask q u e s t i o n s regarding this research study and these que s t i o n s have been answered to m y satisfaction." "I have the right to ask questions that I m a y have at any time during the study." "In giving my consent, I understand that the participation of my c h il d in this study is v o l u n t a r y and that my child or m y s e l f m a y withdraw t h e m at any time for any reason, by contacting my child's
66
t e a c h e r ." "The researcher has m y p e r m i s s i o n to m onitor m y child's reactions and a u d io tape t h e m during the s t u d y ." "I a u t ho riz e the rese ar che r to r el e a s e information o b t a i n e d during this study to s c i e n t i f i c literature and have been assured that m y chi l d ' s name will not be used." I u n d e r s t a n d that ______ e l e m e n t a r y school is not respons ib le for any i n j u r y i n c u r r e d during this study." "I have been given the t e le pho ne num b e r s of the r e s e ar che r and c h a i r p e r s o n of G r a n d Valley State U n i v e r s i t y Human Research R e v i e w Committee. I may co ntact any them at any time.
Pa rt icipant's name signature
Parent's
67
A PP END IX F Perso nal data sheet
APPENDIX F
Personal Data Sheet
ID# Your a n s w ers to the following questions will be helpful in d e t e r m i n i n g if there are particular factors that affect your child's perception of death. Pleas e take the time to c a ref ull y a ns we r these and return them w i t h the consent form. As with the rest of this study, this information is c o nf ide nt ial and will be used for group data pur pos es only. Date : 1.
What
2.
Is your child 1. M a l e _________
3.
Has your _____ 1. _____ 2. 3. _____ 4. ______5. ______ 6. ______7 . ______8.
4.
5.
6.
is your child's birth date? or 2. Female_________
child exper ien ce d a death? Mother Father Grand par en t Sibling Friend (friend's age:_________ ) Ot h e r _________________________________ Pet None
Has your child a tte nde d a funeral in the last 3 years? l.Yes 2. No___ C hec k the most appropriate answer r e g ard in g religious activities. I . Attends services weekly 2. Attends services at least m o n th ly 3. Attends services occasionally 4. Does not a tt end religious services What is your highest level of education? Use A for parent and B for other adult caretaker. A. circle one: m o the r father grandparent s t e p - p a r e n t other I . Less than high school graduate 2. High school graduate 3. T e c h n i c al /co ll ege classes
68
4. C o l l e g e graduate 5. Some m a s t e r ' s classes 6. Master/Ph. D B. circle one: moth er father grandparent step- pa ren t other 1. Less than high school g r a d u a t e 2. High school graduate 3. T e c h n i c a l / c o l l e g e classes 4. C o l l e g e graduate 5. Some m a s t e r ' s classes 6. Master/Ph.D 7 . Your current m a r it al status 1. Never m a r r i e d 2. Di vorced 3. Widowed 4. Married
69
APPENDIX G Consent
f r o m Dr.
Sara Smilansky
APPENDIX G
IBoAR D OF(^EW ISH ÎBdUCATION
o f Greater Washington Early Childhood Education Department 11710 Hunters Lane. Rockville. Maryland 20852 Telephone: 301-984-44S5, X. 311 TTY: 301-984-1670 FAX: 301-230 0267
Kahbi B ruce A ft. President A vi S . W est. ExecuOue Director Dr. Uiricun Feinberg. Director
June 4, 1998
^
Ms. Diana Schramm 901 Boynton Avenue SE Ada, MI 49301 Dear Diana, Dr. Sara Smilansky would like you to know that she is delighted that you will be using the Smilansky Death Concept Questionnaire in your study. She wishes you great success in your work and looks forward to learning of the results. Sincerely,
Miriam Feinberg
txnertySdnmm
Jewish Continuity Through Jewish EducaUon A B eneficiary Agency o f The U nited Jew ish Appeal F ederation and the U nited Way and Combined F ederal Campaigns A fpikited w ith the N ational Board o f License an d the Jew ish Education Service o f North Am erica
70
APPENDIX H The Smi lan sk y Death Concept Questionnaire
APPENDIX H
Questionnaire for E x a m i n a t i o n of Human and Ani mal
Death
Co nc ep t u a l i z a t i o n of C h ild ren
Smilansky,
Sara.
(1987).
children understand and cope.
On death:
Helping
Peter Lang Pub l i s h i n g
I n c ., New York. The "Questionnaire for Examination of H u m an and Animal Death Co nce p t u a l i z a t i o n of Children" conta in s 26 questions relating to va ri ous aspects of d e a t h concepts. T h ey deal with the following concepts: finality,
causality,
inevitability,
Irreversibility,
and old age.
d e v e lo ped for children from ages 4 - 1 2 .
It was
The questions
are ba sed on two criteria: 1.
Significance of understanding each p a r t i c u l a r concept of death,
to a child's m o u r n i n g process
and to his/her r e ad jus tme nt and co pi n g in the new reality. 2. Relevant i n f o r ma tio n from research a na l y s i s and results
from it's authors empirical studies.
TOOL: Demographics Initials, age, date of birth, gender, loss of family m e m b e r b y death Concepts
related to hu man death:
71
date,
faith,
1. What does it m e a n to die? 2. How do people die? 3. Who gets old?
What is death?
Reasons?
Does everyone get old?
4. What happens to a per son who dies? 5. Does a dead
p e r s o n know that they
6. Does a dead
p e r s o n feel pain?
7. If a person dies,
are d e ad ?
Why?
can that same person b e c o m e
alive again? Why? 8. What if that p e r s o n has not been b uri e d yet? 9. Can a dead p ers o n
Why?
see? Why?
10. Can a
dead pers on hear?
Why?
11. Can a
dead pers on move?
Why?
12. Can a
dead pers on come out of his grave?
13.Does everyone die?
Will you die?
How?
Why?
C o nce pts related to animal death 14. Have you ever seen a d e ad animal? 15. How do animals die?
Why?
16. Does an animal get old? 17. What do we do w i t h 18. Does a
dead
Do all animals get old?
dea d animals?
animal know he is dead?
19. Can a dead animal
feel?
20. If an animal dies an d its buried, live again? 2 1 . If an animal
can that animal
How? is b u r i e d and is put in the tr ash
72
can it become alive again? 2 2 . Can a dead animal see? 23 .C a n a dead animal hear? 2 4 . Can a dead animal move? 25.C a n a dead animal get out of a box by himself? 2 6 . Do all animals die?
73
APPENDIX I Smilansky's Scoring Tool
3. Diagnostic Summary Record of an Individual Child’s Concep tualization of Death , _ ,, . Sara S m ila n tk y
Child’s Name_________________________ Age_____ Sex______ Examiner’s Name __________________ Date______________
3. Diagnostic Summary Record of an Individual Child's Concep tualization of Death C h ild ’s N a m e________________________________A ge______ S e x _______
Examiner’s Name_____________________ Date______________ A. Child’s Scores on Human Death A. Child’s Scores on Human Death CONCEPTS
'J
Possible Score
Child’s Score CONCEPTS
Possible Score
1. Non*Reversibiilty
0 -3
2. Finality
0 -3
1. Non-Reversibility
0 -3
3. Causality
0 -3
2. Finality
0 -3
4. Inevitability
0 -3
3. Causality
0 -3
S. Old Age
0 -3
4. Inevitability
0 -3
S. Old Age
0 -3
6. Total Score for Human Death
0 -li
6. Total Score for Human Death
o -ii
Child’s Score
HD fO m z o H X
Child’s Scores on Animal Death B. Child’s Scores on Animal Death CONCEPTS
Possible Score
Child’s Score CONCEPTS
Possible Score
1. Non-Revenibiiity
0 -3
2. Finality
0 -3
1. Non-Reversibility
0 -3
3. Causality
0 -3
2. Finality
0 -3
4. Inevitability S. Old Age
0 -3
3. Causality 4. Inevitability S. Old Age
0 -3 0 -3
6. Total Score for Animal Death
0 -3 0 - IS
6. Total Score for Animal Death
Child’s Score
0 -3 0- 15
203
203
APPENDIX J Pre-te st Script
APPENDIX J
PRETEST SCRIPT
I will class.
formally greet the group at the beginning of I will also re-introduce m y s e l f and explain the
p u rpose of me being in their classroom. "As most of you know my name is Mrs.
Schramm.
This
week I am going to ask you to help m e with a project that I a m doing.
I will be asking each of you to come back to
the o bs e r v a t i o n room one at a time.
I will explain more
about what we are going to do then." I will
then call the children,
study,
back to the observation room individually and
close the door. because
who are involved in the
They are comfortable with this routine
they use it for individual re ad i n g time with
c l a s s r o o m volunteers. "Good morning,
(child's n a m e ) .
see you this morning. except I am in college. I n ee d your help with.
I a m very glad to
I am a student just like you, I have an a s s i g n m e n t to do that I'm going to ask you a few
que sti on s and I would like for you to ans wer them the best you can.
There are no right or w r o n g answers,
an y t h i n g you say is right.
so
I am g o i n g to tape record
what you say and I might write down a few notes.
75
I am
doing this to help me re mem be r what you say. tell any of your c l a s sm ate s what you say. take very long. class.
It does not
After w e are done you can go back to
Do you have any questions?
You can ask questions
at any time during our time together. Great,
I will not
Are you ready?
let's get start ed"
After the questionnaire Is complete the c hild will be given a small toy and th a n k e d for their c o o p e ra tio n and honesty. "You have done a g r e at job. me with this project, as a reward.
Because you have helped
I w o u l d like for you to take a toy
I would a lso like for you to remind your
parents that you are h e l p i n g me with m y as sig nme nt today. I'm sure that they would
like to hear about It."
76
APPENDIX K I n ter ven ti on questions
APPENDIX K
SCRIPT
FOR INTERVENTION Q UE STI ON
I will gr eet the children, them,
r e -in tr odu ce myself to
and rev ie w the purpose of my b e i n g in their
classroom
(see script for q u e s t i o n n a i r e ) .
The following
questions will be used after reading "The Fall of Freddie the Leaf" to ge n e r a t e information a n d direct the conve rsa ti on aro u n d death concepts. b a se d on Sm il ans ky' s
These questions are
five concepts of death from which
the S m ila ns ky Death Questionnaire was developed. 1.
Ca u s a l i t y of death - What h a p p e n e d to Freddie?
2.
Finality of death - Does Freddie know what is happe nin g to him?
3.
Why?
I r r e v e r si bil ity of death - Can Freddie go back to living in the tree after he has
4.
fallen off?
Why?
I n evi ta bil ity of death - Does the same thing happ en to all of the leaves?
Why?
Old age - What leaves get old? old?
77
Do all the leaves get
APPENDIX L Post-test script
APPENDIX L
SCRIPT FOR POST-TEST A f t e r completing the interve nt ion portion of this study, the c hil dr en in the study will again be asked to come ba ck to the observation r o o m individually. "Hello
(child's n a m e ) .
Do you remember when I asked
you a few questions e arl ier in the week? g o i ng to ask a few more questions. to these questions.
The same rules apply
Th ere are no right or wrong answers,
so any answer you give is right. Again,
Today we are
Try to be honest.
I will not share your answers with any of your
classmates.
It will only take a few minutes and then you
can return to class.
Do you have any question about the
que sti on s?
we will start when you are ready."
Terrific,
A pos t-t est will be given to each child in the study. The post-test will be gi ven using the same gu id elines as the pre-test.
The child a g ain be thanked and o ffe red
an ot h e r small toy.
78
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