Bereavement and Loss

Benjamin S. Siegel

Maria Trozzi

I. Description of the problem. It is estimated that 5% of all children will experience the death of a parent by age 15 years, and 40% of junior and senior high school students have experienced the death of a friend or an acquaintance their age.
- A. Coping with loss. The task of children who experience a great loss is to attempt to understand what happened and why the death occurred, to mourn the lost person in their own way and at their level of cognition and affective development, and to construct an enduring inner reality of that lost person and the lost relationship. Long-term mental health outcomes of bereaved children are influenced by:
  - The age at which death takes place
  - The person who has died (parent, sibling, friend, or relative)
  - The nature of the relationship between that person and the child
  - The nature of the death (illness, suicide, SIDS, AIDS, murder, accident; was it witnessed by the child)
  - The child’s history of losses
    
    It is useful to divide childhood into four major age categories to understand the child’s knowledge of and emotional reaction to death and loss (Table 90-1).
- B. Communication issues. Most adults in our culture feel uncomfortable talking with children about death. Death is viewed as outside the normal cycle of life, something to be fought against and to be denied. This attitude is problematic when the adults who are most needed by children are in the midst of their own mourning and grief, so that their grief intensifies when their children question them or discuss the death. Other times, adults may wish to protect children from emotional distress by denying the loss altogether. Well-meaning adults may use euphemisms to explain about death, such as “going to sleep,” which may be confusing to children and make them afraid to go to sleep or fearful when a loved one is sleeping.
  - Adults must help children to come to terms with difficult questions: “What is death? Can it happen to me? Can it happen to some other loved one? Am I responsible for the death? Who will take care of me now? Why did the person die? Where is the dead person now? Why won’t the dead person come back?”
II. Role of the primary care clinician. The primary care clinician, especially one who has had a long-term relationship with the patient and family, is in an excellent position to provide initial counseling and appropriate referral (Table 90-2). Competence in this area requires not only the willingness to explore these issues with families but also an honest appraisal of one’s own thoughts and feelings about the meaning of death.

III. Management. The most important goal for the clinician is to help the parents address their thoughts and feelings about the loss and to encourage them to be emotionally available to their children. The clinician should encourage the adult caretakers to communicate with the children and remember that accommodation and adaptation to the death of a loved one are a continual process, often lasting a lifetime. Children confront the loss at each stage of development as they gain a greater understanding of the world and themselves, and they experience new feelings at each stage of development. Since it is a developmental process, children grieve longer than adults, as they apparently re-grieve at each developmental stage. Clinicians need to remind parents of this phenomenon. Nurturing and support over time by family and friends are the best healing experiences for the bereaved child.

A. Very young children (to age 2 years).

1. Encourage parenting figures to provide consistent care in a familiar environment since children at this age react to death primarily with feelings of separation and loss.
2. Familiar toys, appropriate transitional objects, and consistent caretaking are crucial. Frequently, family members are involved in their own grief and have little energy to spend with the infant or toddler. A close relative or even a babysitter well known to the child could be engaged to provide the support of which others may be incapable.

Table 90-1. Cognitive and affective stages of grief and loss

Age	Cognitive understanding	Emotional/affective	Potential symptoms
Young children less than age 3	Death is separation, abandonment, change	Feelings of loss	Sadness Fearfulness Poor feeding Sleep problems Irritability Developmental delay Regression Increased crying
Preschool (3-6 yr)	Realization that death exists	Guilt (I am responsible)	Delayed grief
Preoperational (prelogical)	Reversibility of death (3-5)	Shame	Enuresis
Magical thinking	Death equals sorrow of others	Fear of punishment because of my thoughts, feelings, and actions	Encopresis
Fantasies	Death is temporary	Fear of catching whatever caused the death	Sleep disturbances
Causation of thought.^*	Death is catching	Fear of other loved one dying	Nightmares
Egocentric	Fear that sleep = death	Anger at loved one	Temper tantrums
	Loving someone is dangerous	Denial	Hyperactivities
	Dead people still eat and breathe		Loss of control of behavior
School age (6-11 yr)	Death is permanent	Anger, sadness
Concrete operations (logical)	Death will not happen to me	Guilt
Problem solving	Biologic understanding of death	Some fear of retribution	Somatic complaints
	Death is universal	Denial	Resistance to going to school
	Dead people do not think, feel		Decreased school performance
	Dead people can sometimes look alive		Inattention, fighting, daydreaming, failure to complete work
			Acting-out behavior
Adolescence (12+ yr)	Death as an inevitable universal process	Strong denial of death	Delinquency
Formal operations (abstract logical)	Death as irreversible	Anger	Drug and alcohol abuse
	Death can happen to me	Guilt	Somatic complaints
	Idealization of dead person	Sadness	Depression
		Embarrassment	Suicide ideation
		Wanting to join loved one	Sexual acting out
			School failure
^*The idea that one’s thoughts or wishes can cause something to happen.

Table 90-2. Role of primary care clinician

To acknowledge one’s own feelings of sadness and loss

To demystify and explain the reasons for death at a level the child can understand

To encourage the child to ask questions and explore his fear and fantasies

To encourage the child to see the body of the person who has died if the child and adults feel comfortable, and to participate in the religious or cultural rituals of grief and mourning as practiced by the family

To explore hidden feelings and memories of the dead person

To explain to parents different stages of cognitive and affective development of children and anticipate specific kinds of grief reactions

To deal with and accept any of the displaced anger family members may have. To monitor the grief reaction and refer for mental health consultation when appropriate

To support the child and family over time

To consult with the school or other community institutions as appropriate

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