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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Bereavement and Loss
Bereavement and Loss
Benjamin S. Siegel
Maria Trozzi
