NSG 217: Family Dynamics & Professionalism

Major Goal for Pediatric Nursing

• Improve the quality of health care for children and their families

  • So talking about pediatric nursing specifically, the major difference is that often times you are treating the family more than you're treating the patient because they are too young and even if they are older the parent is in control of the child's health care so just make sure that you are kind of involving both parties equally 

Health Promotion in Children

• 6 Categories Of Behavior:

  • Tobacco Use

  • Behavior that results in Injury & Violence

  • Alcohol & Substance Use

  • Dietary & Hygienic Practices that cause Disease

  • Sedentary Lifestyle

    • one of the big things that they've been focusing on for a while is the sedentary lifestyle which is leading to kids that are overweight and obese because our kids are spending more time on screens and phones and things like that and not getting outside and playing and running around 

  • Sexual Behavior that causes Unintended Pregnancy & Disease.

• the overarching goals are to basically increase their quality and length of healthy life and also to eliminate any health disparities that exist 

Nutrition

• Nutrition is an ESSENTIAL component for healthy growth and development. 

  • specifically brain development 

• Human milk is the preferred form of nutrition for all infants.

  • and human milk as we've said before “breast is best” however fed is really best If the mom's not comfortable breastfeeding or isn't producing breast milk you know it's absolutely okay to feed the child formula 

    • the reason why they say that breast does best is because it gives things like micronutrients immunologic properties and several different enzymes that enhanced digestion and absorption of various nutrients 

Family Centered Care

• Family-Centered Care (FCC)

  • Recognizes the family as the ONE CONSTANT in a child’s life. 

    • family is the one constant in a child's life, it's the one thing that kind of doesn't change for them and so because of that we want to make sure that we include the family and we enable them and Empower them to be part of their child's care 

• 2 Basic Concepts of FCC:

  • Enabling

  • Empowerment 

  • Key Elements of Family Centered Care

**Systems must support these & Needs of ALL family members should be met

• family is the one constant in a child's life, it's the one thing that kind of doesn't change for them and so because of that we want to make sure that we include the family and we enable them and Empower them to be part of their child's care 

• we also need to keep in mind that the definition of family is whatever that individual considers family to be 

  • you do have to be careful with that though because even though you know someone’s like family to them they're not family and so you have to take into account things like HIPAA and that sort of thing 

What are the two basic concepts in family centered care?

• 2 Basic Concepts in FCC:

  
  

  • Enabling families by:

    • Creating opportunities for ALL family members to display their current abilities & competencies 

      • that could be something as small as changing a diaper especially if you have a baby that was born really premature that can be very scary and so allow them the opportunity to do that and praise them for how they we're able to complete that task 

    • Acquiring new ones that are necessary to meet the need of the child & family

  
  

  • Empowerment

    • as far as empowering them basically you want to help them get a sense of control because when their child is admitted to the hospital for whatever reason they really feel like they've lost control and someone else that being like the medical team the nursing staff they are the ones now in control of their child so making sure that you Foster their strengths their abilities their actions and really encourage them is extremely important 

    
    

    • Interaction of professionals with families in such a way that families maintain or acquire a sense of Control over their lives & make positive changes that result from helping behaviors that foster their:

      • Strengths

      • Abilities

      • Actions

Atraumatic Care

• The provision of therapeutic care that eliminates or minimizes the psychologic & physical distress experienced by:

  • Children

  • Their Families

  
  

• Goal:

  • First-Do NO Harm

  • Minimize Separation from the Family

  • Promote Sense of Control

  • Prevent/minimize Bodily Injury & Pain

    • Pain prevention?

  
  

• we try to keep their room their safe space

  • and so if there's something that we're going to do that's going to cause them to be in pain or uncomfortable pediatric hospitals have treatment rooms it's expected that you take the child down to the treatment room if you're doing something like starting an IV putting in a foley catheter straight catheter, really even if you're getting like a blood sugar you know it should be done in the treatment room I can tell you from experience that that is not always done as it should be but it is the expectation

Role of Pediatric Nurses

• Pediatric Nurses MUST relate to:

  • Children & Their Families

    • with children it's their parents that are in control of their treatment so that's the biggest difference or shift that you're going to see 

• Therapeutic Relationships

  • Essential foundation for Quality nursing care

  • Possess caring, well-defined boundaries separate the nurse from the child and family

    • it is important that you separate yourself to some degree from the child and the family because if your working in an area where you have children that are admitted for long periods of time you do start to get attached to that family and that child

• Advocate

  • Child

  • Family

    • of course we know that we're advocating not only for the child but the family as well and it's really our job to help them make sure that they are making informed decisions but our partner in that is really social services or social work because they will really help them as far as you know knowing what health services are available and things of that nature 

• Nurse assists them in making informed choices:

  • Aware of all available health services

  • Informed of treatments & procedures

  • Involved in the child’s care

  • Encouraged to change or support existing health care practices
    
    

• it's important that you consider family structure when you're taking care of these children because you can't assume that there's a mom and a dad you know it may be a single parent family it may be a same sex family

  • it's important when you are entering the room and there is an adult at the bedside that you introduce yourself and you immediately clarify who the individual is at the bedside and that is important for a number of reasons

Communication with Parents

• Establish a Setting

  • Introduce yourself—as the RN

• Ensure Privacy & Confidentiality (HIPAA)

  • Confidentiality of teenagers too

    • if they are under the age of eighteen their parents are still technically in charge of their medical care and therefore are able to know their medical information with the exception of certain diagnoses on pregnancy things of that nature

      • so it's important to let the teenager know you know I do have to discuss this with your parents or if your parents ask I can't keep this from them or so on and so forth 

• Encourage Talking

  • but it's very very important especially with the Adolescent population that you encourage them to talk because a lot of times talking to them is going to help get to the bottom of what is going on with them

    • sometimes of course cultural awareness is a huge thing

• Direct the Focus

• Listening & Cultural Awareness

• Silence, Empathy, & Providing Anticipatory Guidance

• Avoid Communication Block

  • Open Ended Questions & Expressions of Feelings

• A lot of what you're doing is communicating with the parents

  • You still need to include the child in the conversation if they are old enough to be part of the conversation and I'm talking like just even toddlers like acknowledging them talking to them you know making them feel like they're not being ignored

What should the nurse take into consideration when interviewing a parent?

• if the nurse is going to interview the parent for any reason it's important to make sure that we give the child something to do while that interview is occurring 

  • so in this instance you know the child has the toys that they're playing with and Mom is discussing you know whatever it is with the nurse 

Communication with Families Through an Interpreter

• Know your institutional policies!

• we have to understand that family cannot interpret medical information 

  • now if you want to ask a question like you know are you thirsty do you want water or something like that then yes they can interpret that but when it comes to medical information you absolutely have to have a certified interpreter 

Principles of Communication with Children

• Guidelines for Communication With Children 

• Make communication Developmentally Appropriate

  • doesn't always mean based on their age they may be 8 years old but have the developmental capacity of a 4-year-old so we need to make sure that we're talking to them as we would talk to a four year old 

• Get on child’s eye level

  • that removes kind of like the scary bit of you kind of looking over them and doing things to them

• Approach child gently/quietly

• Always be truthful

  • you want to make sure that you are always truthful to them because if you're not they will shut down communication pretty much immediately especially when you start getting like to school age and Beyond so if they are asking if it's going to hurt and you're doing something that's going to hurt like drawing blood or starting an IV or whatever you need to tell them like yes it's going to hurt but it will only be for a second you know and then it will be over and we won't have to do that again or whatever 

  
  

• Give child choices as appropriate

  • when it's possible give them choices you need to give them choices that aren't like yes and no 

    • so like you don't want to say you know do you want to get washed up because they're going to say no, so you would say hey we're going to get washed up would you like to take the washcloth and wash your arms or would you like me to use the washcloth and wash your arms you know so still getting choices but the bath is going to happen

• Involve Child in Communication

  • kids that are five and under are very egocentric so they only see things in relation to themselves so it's very important that you include them 

Principles of Communication with Children (cont’d)

• Avoid Analogies & Metaphors

  • kids take things very literally 

• Give Instructions Clearly & in a Positive Manner

  • you have to be very clear with your instructions and no matter what it is that you're instructing them on you have to make it seem like it's a positive thing it's a happy thing that sort of thing 

• Avoid long sentences, medical jargon; think about “scary words”

  • we want to avoid like words that would be considered scary words like Cuts, stick, tubes even blood pressure because it has the word blood in it you know most of the time we say you know we're going to give your arm a hug or give your arm a squeeze or you know whatever it may be

• Give older child opportunity to talk without parents present

• Be Culturally Aware

Communication

• When dealing with the young child or infant most communication will be with the parents

• Communication with the child and infant will come in the form of PLAY 

  • PLAY IS THE UNIVERSIAL FORM OF COMMUNICATION

• Older children, communication will come in the form of direct questions

• We want to make sure that we allow them to play whenever possible and understand that they will oftentimes communicate something to you that they wouldn't otherwise communicate when they're playing

What is the universal form of communication?

• Play

Infants: Developmentally Appropriate Communication

• Nonverbal

• Crying as communication

  • Types of cries

    • Hunger

    • Pain

    • Body restraint

    • Loneliness

• and they have different types of cries now we as their caregivers may not recognize these but most of the time a parent can tell
  
  

• so you at this age can say anything to the infant as long as you are using the right tone of voice which is like a cheery voice 

  • they do respond to voices so if you raise your voice or you have kind of like a deep tone to your voice it may scare them and make them cry so just keep that in mind 

Early Childhood: Developmentally Appropriate Communication

• Focus on CHILD in your communication—Egocentric 

  • so make sure to include them when you're talking

• Explain what, how, and why

• Use words they will recognize

• Be consistent: don’t smile when doing painful things

• They assign Human Attributes to inanimate objects-ANIMISM

  • Fear objects may jump or bite

• make sure that you don't call them like kids or babies because they feel like they're you know they're big and so they can perceive that as kind of like an insult

Animism

Seen in Early Childhood

• They assign Human Attributes to inanimate objects-ANIMISM

  • Fear objects may jump or bite

• so it's important that you allow them to ask questions about devices & you allow them to touch it you know feel it those sorts of things so that they are less afraid of it

School-Age Years: Developmentally Appropriate Communication

• School-Age Years

  • Explanations & reasons for everything

    • make sure that they are clear about what is going on

  • Interested in the functional aspect of procedures, objects & activities

• Have a heightened concern of Body Integrity

  • they really have a heightened concern with body Integrity which means they're sensitive to anything that might constitute a threat or a suggestion of injury to their body

Adolescent: Developmentally Appropriate Communication

• Be honest with them

• Aware of Privacy Needs (HIPPA)

  • Again their parents are still their Guardians and they are privy to their medical information 

  
  

• Think about developmental regression

  • even though they're adolescence they might have some developmental regression when they are sick or admitted to the hospital such as things like you know wanting their mom when you know prior to getting admitted to the hospital you know they were seeking Independence 

• Importance of PEERS

  • and then of course peers are extremely important to them they worry while they're in the hospital that they're friends are going to forget about them it's really important that you reassure them

• Communicating With Adolescents

Play in Communication

• Universal Language of Children

  • Effective Communication Technique

    • Peek-a-boo with an older infant of developing trust 

• Children’s “work”

• Play

  • As THERAPEUTIC intervention

  • As stress reliever for child & family

  • As pain reliever, distracter

  • As barometer of illness

    • if you have a child that is not wanting to play it can be a barometer of them being ill

• infants learn through all of their senses so allowing them to play with various things is really going to help them grow and gain new skills 

Communication Through the Use of Traditional Objects

• Communicate through objects such as:

  • Dolls

  • Puppets

  • Stuffed Animals

• that object can go with them to the operating room to the point that they are anesthetized and then at that point they will take that object away just because they need to create a sterile field

  • that just helps the child feel safe and it also helps them transition 

General Approaches Towards Examining a Child

• Head-to-toe sequence for assessing adult clients

• Sequence for pediatric assessments generally altered to accommodate child’s developmental needs

  • for a pediatric assessment we really have to alter it depending on the age of the child and their developmental level so you might have to go back a couple times to get a full assessment of a child because it may require for you to build kind of a little level of trust with them before they let you do all the pieces of the assessment that you need to do 

  
  

  • if you go in and they are quiet and they are sleeping I would try to start with things like listening to the lungs or listening to the heart because if they wake up and they're crying and things like that you're not going to be able to hear those 

  
  

  • in addition if you have a kid that you know wakes up and they're super upset if you're trying to get vital signs you're going to notice that blood pressure is elevated heart rate is elevated so you're probably going to need to wait on those things until they calm down and again that might require another trip back into the room so just keep that in mind 

Preparation for Diagnostic and Therapeutic Procedures

• Psychological prep

• Establish Trust & Provide Support

• Parental Presence & Support

  • This is difficult for parents too

  • you just don't want to give them that sense of false hope

• Provide an Explanation 

  • Age appropriate

  • Consider Developmental Age

Playing with Medical Devices

• Playing with medical (therapeutic play) provides children with the opportunity to play out fears and concerns with supervision by a nurse or child life specialist.

  
  
  

• Allowing kids to have that therapeutic play where they're playing with medical devices that you know at some point are going to be utilized on them like a blood pressure cuff or a stethoscope or whatever it may be will definitely help with their fears and their concerns 

• often times your child life specialist can help facilitate this

Play Activities for Specific Procedures

• How to encourage fluids

• Cough & deep breath 

• So there are things that we are going to need kids to do that you're not going to be able to do in the same manner that you would do with adults 

  • so for instance post-surgically if you need an adult to take you know a deep breath and cough you would give them an incentives spirometer and explain that to them and that they need to do 10 breaths every hour and so on and so forth 

  • with kids, even your school age kids are not going to understand how to use an incentive spirometer so you are going to have to make a game out of it 

Definition of Family

• No universal definition

• What an individual considers it to be.

• Just understand that if a person considers them family even though they're not necessarily family we treat them like family while being cognizant of our adherence to HIPAA

Traditional Nuclear Family

• a traditional nuclear family 

  • which is where you have a mother and a father they're married and then they have their biological children 

Nuclear Family

• nuclear family 

  • which means there are two parents and their children but they're not necessarily married the children may be biological children they might be stepchildren they might be half siblings they might be adopted so that's the nuclear family 

Blended Family or Household

• a blended family or household is where you have step parents and step children 

Extended Family

• Extended family 

  • you see this more frequently in certain cultures where they have grandparents Aunts Uncles cousins Etc that all live in one household Under One Roof and sometimes the grandparents kind of assume the parental role other times the actual parents assume the parental rule it just kind of depends on who's working outside of the household 

Family Structure Continued

• we also have single parent families which are seeing more and more of 

• same sex families 

  • where there's two mothers two fathers we're seeing more of those 

• we're also seeing the roles change as we're seeing more stay at home dads we're seeing a lot more families we're both parents are working and that changes the dynamic of the family as well 

• and we're starting to change in our culture what we see as acceptable 

  • you never want to assume who is in the family you always want to ask you know what is your relationship to the child you don't want to assume because there's a female at the bedside that that's the child's mother or vice versa if you have a male at the bedside

Family Roles & Relationships

• Family strength and unique functioning styles

  • The nurse can use strength and styles to meet the patient’s needs

    • we want to use their strengths, so for instance if you know that they're a religious family maybe they have a church family that you might suggest that they lean on to help you know perhaps with meals or if they have other smaller children that they need assistance with while they're visiting, those sorts of things 

• Parental roles

  • Family size and configuration

    • We have family sizes that are smaller today than when our parents and Grandparents were young 

      • so just considering that family size and configurations different than it used to be, 

        • when you have small families parenting tends to be more intensive children tend to be compared often with their peers or their friend groups and you have a child who generally identifies more strongly with their parents and is likely to ask for advice from them 

        • so with large families essentially they're able to the kids tend to be able to adjust to changes more easily just because in a larger family there's a lot of coming and goings and lots of changes occurring having cooperation within the family is essential they do have reduced one to one contact with their parents so siblings a lot of times tend to turn to each other instead of to their parents 

    
    

  • Changing roles in the family

Parenting and divorce

• Impact of divorce on children

• Telling the child

  • it's very important that the parents prepare the child for the divorce 

    • it's great if initially the parents can have that conversation together with the child it will really help them understand it more and be able to cope with it better essentially 

• so if you have a child that's going through a divorce in their family essentially their age their gender are going to kind of depend on how they react to it and then the outcome 

  • so is it a friendly divorce or is it a divorce or the parents are battling back and forth 

  • you may notice that these kids have trouble sleeping they might have a drop in their grades if it's a school age child 

Custody and parenting partnerships

• custody is really provided to the parent that's the best able to provide for the child's welfare 

  • sometimes that means that each parent is equally able to provide for the child's welfare and therefore custody may be 50/50,

  • custody might be awarded to one parent with visitation to the other 

  • it can be divided multiple different ways where maybe one child will live with one parent and other children live with the other parents 

    • usually they try to keep the kids together but that may not always be the case 

• they can have joint custody 

  • if they have physical joint custody parents alternate the physical care of the child 

  • if they have joint legal custody the child lives with one parent but both are Guardians 

• it's important that we know about custody arrangements so we can always make sure that the correct parents is signing consent for certain procedures or surgeries 

Family Assessment

• Family Assessment is a component of the history taking process

• It is a collection of data about the family and the relationships of the family members

• Also assess for the following: 

  • Type of home (number of bedrooms)

    • Sleeping arrangements

  • Education and occupation of family members

  • Cultural & religious traditions

    • are there any cultural and religious Traditions that will impact how we care for the child 

  • Communication between members

    • are they on good terms are they on non-speaking terms 

      • because that might mean they don't speak that we have to give the same story twice whereas if you know there's good communication between the members of the family

• Recognizes the family as the ONE CONSTANT in a

   child’s life. 

**Systems must support these & Needs of ALL family members should be met

• don't forget about the siblings you want to make sure that you're paying attention to all members of the family and they all need to be included in decisions to change the care of the child 

  • so for instance if we're going the palliative care hospice route you don't want to just consult palliative Care or hospice without talking to the parents first so that they can be a part of that of that care

What are the 2 key elements of family centered care?

• 2 Basic Concepts of FCC:

  • Enabling

  • Empowerment 

  • Key Elements of Family Centered Care

Children with Chronic or Complex Diseases

• Scope of the problem

  
  

  • Increasing viability of preterm infants

    • we've made a lot of effort over the years caring for children that are born early specifically those children that are born before 30 weeks but those children still have lifelong chronic illnesses 

  
  

  • Portability of life-sustaining technology

    • we do have more life-sustaining technology that's portable so for example we have portable vents we have portable oxygen we have portable IV pumps we have a lot of things that you know the parents can just hook up to their child and take out with them 

  
  

  • Life-extending treatments

    • we have a lot of increase in life extending treatment so for instance we have better antibiotics we have chemotherapies that are more specific to the type of cancer that the child may have those sorts of things 

  
  

  • Rise in the numbers of children with complex and chronic diseases

    • we don't necessarily have an increase in that, but we have an increase in chronically ill children that are able to survive because of the life-sustaining technologies that we have that we didn't use to have

The Family of a Child with Chronic or Complex Conditions

• Effects of the child’s chronic illness or disability

  • for the family of a child with chronic or complex conditions it's important that we're always looking at what impact that child's illness has on the family 

    
    

    • Parents

      • Parental roles

      • One remains at home to mange 

        • Other parent may feel left out

    
    

    • Role Conflict

      • Burden of care

        • is it impacting the parental roles are they having caregivers strain 

      
      

      • Financial burden

        • they may have to have one parent that stays at home to manage child care and therefore they have Financial burdens 

      
      

      • Hereditary nature of disease

        • they may fear having anymore children

      
      

      • Fear of child dying

• the RN can help to avoid conflict by making sure that teaching addresses the specific stressors of that family especially for those that have an identified impact on the parental relationship or marriage diagnosis and that child actually going home are the most critical times for parents because they may feel very overwhelmed and we need to make sure that we're providing appropriate education to them

Siblings of a Child with Chronic or Complex Conditions

• Siblings 

  • May have a distorted view of the truth

    • their parents may not be completely be honest with them as far as how ill their siblings are 

    • they only over hear parts of conversation so they're usually going to think the worst or they may be completely oblivious as to how their sibling is 

    
    

  • Supporting Siblings of Children with Special Needs

    • Promote Healthy Sibling Relationships

    • Help Siblings Cope

    • Involve Siblings

• the siblings may need play therapy as well 

• jealousy and resentment or not uncommon just because they feel like that sick sibling is getting all of the attention 

  • and it's important that we encourage the parents to make sure that they're showing emotions to the siblings especially if the siblings are older and helping care for the child of special needs 

Coping with Ongoing Stress and Periodic Crises

• Concurrent stresses within the family

  • so any family that has a chronically ill child is going to have an increase in stress within the family 

    • it may be periodic crises so maybe when the the child gets admitted for an acute exacerbation of whatever they're diagnosis is 

• Additional stressors

  • some additional stressors perhaps they're homeless, maybe the parent has an alcohol or drug problem 

• Coping mechanisms

  • Behaviors aimed at reducing tension

  
  

  • when we're watching for coping we really want to watch for avoidance behaviors 

    • so for instance they have a mandatory education that they need to complete before they can take the child home and they just don't show up for those educational sessions they're refusing treatment for the child they're angry or hostile towards staff those are all avoidance behaviors that we need to address and we may need to get Social Services or social work involved

  
  

• Parental empowerment

  • Recognizing, promoting, and enhancing competence

  
  

  • parental empowerment will likely come as they start to master their child's care so they're able to manage that family life the plan for the future, the financial burdens Etc

Assisting Family Members in Managing Feelings

• Shock and denial

  • Especially at diagnosis

    • it's really important that as they adjust they have an open admission that that condition actually exists, they may be in denial of it to begin with 

    • they may need information repeated they can't believe that this is real so they may ask the same question over and over again because in their mind they're really hoping for a different answer

      • important to just give them consistent answers

• Adjustment

  • our goal for nursing is really to assess their ability to adapt to whatever this disease process is causing, to change their family so the effects of the crisis, especially offering emotional support and guidance early on. 

  
  

• Reintegration and acknowledgment

• Establishing a support system

  
  

• some realistic expectations about how family life will be now so it's kind of that anticipatory guidance 

Nursing Care of the Family and Child

• Assessment

  • their ability to cope, their parental knowledge levels, they're coping mechanisms 

  • it's important that you observe the responses to this disorder their ability to function adaptive behaviors exploring understanding of their illness and providing support for that child that is affected 

• Providing support at time of diagnosis

• Supporting family’s coping methods

  • Parents

  • Parent-to-parent support

  • Advocating for empowerment

    • Maybe they can be on a committee on that focuses on the disease process that their children have 

  • The affected child

  • Siblings

    • and then of course the siblings making sure that you're always including them because they may feel left out

• so really encouraging the parents to express their feelings

  • they might have an online communication board that they're apart of 

  • being in videos that help support other parents with the same children with the same diagnosis 

The Child with a Chronic or Complex Condition

• It is normal for children with chronic or complex conditions to have periods of sadness and anger that's kind of part of their adjustment to chronic illness so they may go through those things intermittently 

Promoting Normal Development in a Child with a Chronic or Complex Condition

• The thing that we really want to promote is normal development 

• Early childhood

  • Basic trust, separation from parents, beginning independence

  • so in early childhood if they're diagnosed with the disease process the parents tend to be very overprotective they have to understand the child's need for autonomy and socialization outside of just the parental unit 

• School age

  • school age: ask them questions don't just let their parents speak for them 

    • it's important that they return to school as soon as possible so that they have that kind of industry versus you know inferiority and that they have activity 

  • it's important that they keep up on their homework when they're in the hospital if they can because it will decrease the stress that they feel when they return to school after their hospitalization

• Preschool

  • preschoolers: they sometimes feel guilty, they feel like they cause the illness so it's important that we let them know that it's not their fault 

• Adolescence

  • Developing independence/autonomy

  • with adolescence we can help them by identifying what their needs are and allowing them to be an active participant in their care 

    • it's normal for them to participate sometimes in Risk taking Behavior 

      • so let's say they got a new diagnosis of diabetes and now they're not taking their insulin it may be to the point where we need to watch them give themselves insulin or take their oral hyperglycemics so just making sure that they're following the plan of care and it's always important that we allow them to express their opinions on various matters 

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Children’s Understanding and Reactions to Death

• Infants/Toddlers

• Preschool

  • Magical thinker

  • Thoughts are all powerful

  • they're very interested in like what funerals are and what a burial is they tend to feel guilty or responsible for the death of that sibling 

  
  

• Adolescents

  • Most difficulty dealing with death

  • adolescents they have the most difficulty dealing with their own death because they understand what death is and if they're acutely ill with a chronic illness they understand that death may be something that comes to them sooner than if they were not ill 

  
  

• essentially you really don't know how a child's going to respond 

  • then really it depends on the child if attendance at the funeral of a sibling is you know feasible or not it depends on the child not just the age

    • it's really going to depend on the child and how they've coped with the diagnosis and the death of the sibling