The development of children's understanding of death: cognitive and psychodynamic considerations

The cognitive and emotional development of children and adolescents follows a biologically driven, environmentally mediated, and predictable but not entirely invariate sequence. Piagetian, psychoanalytic, and other schools of thought inform an understanding of child development; some of the theories are empirically validated, some not. This framework enables clinicians and parents to approach their children, ill or well, from a developmentally informed perspective. At the same time, as Spinetta's [17] case-controlled study of 6 to 10-year-old children hospitalized either with cancer or non-life limiting illness demonstrated, serious illness itself accelerates cognitive development in often unpredicted ways: "To equate awareness of death with the ability to conceptualize it and express the concept in an adult man-ner denies the possibility of an awareness of death at a less cognitive level. If it is true that the perception of death can be engraved at some level that precedes a child's ability to talk about it, then a child might well understand that he is going to die long before he can say so." In the following articles,the editors invite a critical reading of the empiric and descriptive literature of pediatric palliative medicine that allows an informed and individualized approach to these extraordinary children and their families.