Bereavement Reactions, Consequences, and Care (1984) / Chapter Skim
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Pages 97-142
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From page 97... ...
Bereavement During Childhood an c] Adolescence
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art a::: ::::::::::: :: ~ :::: ::::::::::::::::::::: :::::::::: . As vividly depicted" In the Kathe Ko11witz print entitled Killed in Action, children are especially vz~erabJe to psychological problems after the death of a parent or sibling.
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DEVELOPMENTAL CONSIDERATIONS Individuals continue to grow and develop throughout life, but during no other period beyond childhood and adolescence are specific reactions as likely to be influenced by the level of development. Because the impact of trauma in children depends so heavily on the life stage during This chapter was prepared by Janice L
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Psychiatrists and others have generally been struck by how often major childhood loss seems to result in psychopathology. Studies of adults with various mental disorders, especially depression, frequently reveal childhood bereavement, suggesting that such loss may precipitate or contribute to the development of a variety of psychiatric disorders and that this experience con render a person emotionally vulnerable for life.
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. The controversy centers on the years in between: can a healthy resolution be achieved and how similar are children's and adults' bereavement reactions?
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In Bow~by's view, the argument about children's capacity for "mourning" is in large part terminological, with many psychoanalysts restricting the use of "mourning" to psychological processes with a single outcome-detachment and others using it more broadly "to denote a fairly wide array of psychological processes set in train by the loss of a loved person irrespective of outcome."27
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METHODOLOGICAL ISSUES Most of the literature on bereavement in childhood is based on observations of disturbed children who are in psychotherapeutic or psychoanalytic treatment.~°° These case reports offer valuable clinical information regarding psychological symptoms and processes, but it is difficult to know the degree to which these children in treatment are representative of all bereaved children and the extent to which individual reactions may be idiosyncratic. On the other hand, random samples of bereaved children that provide more methodologically reliable data do not offer the same depth of information.
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Studies of both patient and nonpatient samples report that children respond to loss with similar symptoms. People who interact with recently bereaved children find them sad, angry, and fearful; their behavior includes appetite and sleep disturbances, withdrawal, concentration difficulties, dependency, regression, restlessness, and learning difficulties.
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as -~-~ a)
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Adolescents may respond more like adults, but they may also be reluctant about expressing their emotions because of fear that they will appear different or abnormal.89 Intermediate Effects A limited number of investigators45 46 8i ii6 ~26 ~37 followed cohorts of parentally bereaved children for one to six years after death. Others {e.g., Lifshitz93J made single assessments some years after the loss.
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In a study comparing bereaved kibbutz and urban children, Kaffman and Elizur78 found that 48 percent of the kibbutz chidden and 52 percent of those in cities showed persistent symptoms of "pathological grief" (which the authors define as "the presence of multiple and persistent clinical symptomatology of sufficient severity to handicap the child in his everyday life within the family, school, and children's group, persisting for a minimum of two months"J and displayed signs of marked distress, emotional insecurity, and psychological imbalance IS months after notification of their fathers' deaths. That normal kibbutz children did not fare a great deal better than city children suggests that the social supports available in the kibbutz setting and the perceived less central role of the parents did not protect the youngsters from stress.
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Severe depressions were most likely in subjects whose mothers were already depressed prior to their husbands' deaths, suggesting children's emotional states may be linked to identification with the surviving parent rather than a pure response to loss. Stoned suggests that parental death may precipitate a depressive disorder in adolescents already at risk for manicdepressive disorder of the depressive type.
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Most of these researchers used psychiatric patients as subjects, although community samples have also been studied in more recent years. The emphasis has generally been on the consequences of parental death, with some attempt to further specify risk factors in terms of the sex of the deceased parent and the age and sex of the bereaved child.
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Research data examining the link between early loss and adult depression are only suggestive, however. In a review of controlled studies to determine if a link existed between childhood/adolescent bereavement and adult-life depression, [ioy694 found that ~ out of ~ ~ studies29 3i 38 4i 49 72 i03 i2s reported significant increases in depressive disorders among the bereaved group; childhood loss of a parent increased the risk of depression by a factor of two or three.
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These difficulties seem to occur more often if the loss happened when the child was between 7 and 12, and if the deceased parent was of the same sex. They hypothesize that these problems have their roots in identifications with the dead parent inch in the "lack of experience with the dead parent in developmental stages that go beyond the point of loss." Because the adults who experienced childhood bereavement at times do not expect to live longer than their parents did, some avoid emotional intimacy with their children as if to prevent too much grief and suffering if they die.
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Despite a general trend toward greater adjustment, however, 39 percent of the previously normal sample continued to show signs of emotional distress four years after their fathers had died. Shifts in Se~f-Concepts Folio wing Bereavement A major area of concern regarding psychological functioning following bereavement relates to negative shifts in self-concepts and selfesteem.
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Based on their extensive clinical experience with bereaved children, Erna Furman54 and Robert Furman56 have observed that while there is a fairly universal tendency toward self-blame following bereavement, it may be that the resultant sense of guilt is less threatening than is the defended-against view of the self as helpless. If someone feels responsible for a death at least that person feels some sense of control over the environment.
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Common Thoughts, Concerns, and Fantasies As with adults,88 a number of common themes emerge in bereaved children, typically associated with or underlying feelings of sadness, rage, fear, shame. and Quilt.
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She suggests that the good moods that may be observed in bereaved children following parental death represent an affective counterpart of denial. When depressed moods occur, particularly in adolescents, they are usually isolated from thoughts of the dead parent.
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Both Rutted and Bow~by27 have found that bereaved children under the age of five are more susceptible than older children to pathologic outcomes. But whereas Bobby found that children aged six months to four years were at particular risk, Rutter concludes that the third and fourth years of life constitute a vulnerable period because he found an excess of parental deaths among psychiatric clinic patients during those years.
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Retrospective studies of the association between early parental loss and adult-life depression in community samples3~ and studies of women psychiatric patients i5 i7 suggest that girls are more vulnerable than boys to parental bereavement in general and more vulnerable to loss of a father during adolescence. ~7 2i 7i Contrary to the findings cited above, however, Kaffman and Elizur78 found few differences between boys and girls who lost a father, and although Rutteri27 found significantly higher levels of depression in adolescent boys who lost fathers, he concluded that, in general, "there is nothing to suggest that psychiatric disorder was more related to the death of the mother than father or vice versa."
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Widows, usually sad and anxious following conjugal bereavement, often express impatience and irritation with children who simultaneously have special needs.27 59 After a parent dies, modes of discipline often change, with the surviving parent either becoming excessively strict or lax or being inconsistent.27 Rutteri26 found that bereaved children frequently experienced multiple life-style changes in the context of makeshift arrangements following the death, with a few being placed in institutions. Rather than the atmosphere of stability and consistency necessary for a better outcome, 53 the common situation following a parental death may be considerable chaos, disorganization, and a sense of insecurity.
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Fast and Cain48 identified the reluctance of the bereaved child to accept discipline or punishment from the stepparent, competition between the same-sex parent and child for the stepparent, and unfavorable comparisons of the stepparent with the deceased parent as possible sources of difficulty. Hilgard et al.70 found that mothers of subjects in their study who remarried while in their thirties tended to marry men who made inadequate stepfathers, increasing the risk of a poor relationship with the child.
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Pynoos and his colleagues~2 ii3 have reported on children's immediate reactions to witnessing suicide attempts and homicides. Regardless of what has been told to children, it is clear that they know fundamentally what has transpired and that they promptly institute defensive adaptive measures, including denial in fantasy and reworking of the facts in accord with stage-related concerns.
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For example, Dorpat,43 examining the case material of ~ 7 adult psychiatric patients who were seen an average of ~ 6 years after the parent's death, found guilt over the suicide, depression, morbid preoccupation with suicide, self-destructive behavior, absence of grief, and arrests of certain aspects of ego, superego, and libidinal development. Clinical data amassed by Cain and Fast3s on adolescents and adults whose parents committed suicide when they were children suggest that some ongoing ideas and processes in these bereaved children can cause difficulty, including direct identification with the parent in his suicidal act, conviction that they too will die by suicide, and fear of their own suicidal impulses.
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Anticipating Parental Death When a parent is terminally ill, Erna Furmans3 recommends maintenance of personal contact between child and parent for as long as the parent is not drastically altered in appearance or in the ability to communicate with feeling. She notes that visits should not become an unbearable burden nor should they force the child to discontinue other activities.
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Providing concrete recollections of the deceased parent or sibling may also be helpful.53 Photographs and clothing or other possessions of the deceased are meaningful to a child because they represent the deceased person as well as the child's own past relationship with that person. Talking to Children About a Family Member's Death Most authors agree that there is preventive value in educating children about death when they axe young, Tong before death is likely to
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Some Westem observers think that explanations about the deceased going to heaven may be upsetting to children who think and interpret things more concretely than adults.66 84 ii6 Others, however, have remarked on the comfort that religious beliefs can provide following bereavement.97 What is most suitable for a particular child will rlenenr1 ran the f~.t~r~ cited above; what is probably most important is that explanations remain consistent with the family's values and beliefs. A few basic approaches have been found helpful across most families and cultures.
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It is relieving for bereaved children to be told that they will not succumb to the same fate as the deceased, and that they will continue to be cared for. Particularly when dealing with young children, it can be important to reassure a child that the family will remain together and that he or she will be told step by step as each arrangement is planned.53 It is also helpful for young children to gain an understanding of the difference between the self and the deceased.
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Krell and Rat kind have identified some family maneuvers that place surviving children at risk following sibling death: indirect or evasive communication about the death due to the parents' belief that it was preventable, and a tendency to accord surviving children special status by overprotecting and shielding them. Hagin and Corwin67 warn that this need to treasure surviving children can stifle emotional development.
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For example, in a pilot study of bereaved former psychiatric patients, Plotkinii~ found that reactions to birthdays, holidays, and anniversaries of the death were a normal and predictable part of the grieving process. She argues that such late-occurring manifestations of grief should not be confused with pathologic grief, and she advocates using such reactions as healthy opportunities to express feelings about the death.
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A few clinicians have attempted to delineate some bereavement reactions that signal a need for help. Bow~by's27 warning signals regarding bereaved children include the presence of persistent anxieties Such as fears of further Toss or fear that the self will died, hopes of reunion and a desire to die, persistent blame and guilt, patterns of overactivity with aggressive and destructive outbursts, compulsive care-giving and self-reliance, euphoria with depersonalization and identification symptoms, and accident proneness.
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RECOMMENDATIONS FOR FUTURE RESEARCH In order to achieve better understanding of the nature of the bereavement process and its potential impact, there is a need for methodologically sound studies in which representative samples of bereaved children are followed for several years and are compared with nonbereaved children. Following are some of the important questions that should be addressed: · What are the signs and symptoms of pathologic versus normal grief following parental or sibling death?
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Another series of potentially very important studies would involve the random assignment of bereaved children to a variety of different treatment or control groups to determine whether treatment facilitates adaptation to the extent that certain treatment approaches are indeed successful; other studies should identify the essential process or mechanisms by which children are helped. Identification of the most effective methods of preventive intervention for particular children or groups of children, and at what stage of life and what distance from the loss these interventions should take place, would add significantly to current knowledge.
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What happens to bereaved children? Proceedings, Royal Society of Medicine 69:842-844, 1974.
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Childhood bereavement and psychiatric illness. Bntish Journal of Psychiatry212:1049-1069, 1966.
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Bereaved children. Journal of Clinical Child Psychology 3:39-41, 1974.
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Children's reactions to the death of a parent: a review of the psychoanalytic literature. [ournal of the American Psychoanalytic Association 19:697-719, 1971.
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Childhood loss and depression. Paper presented at the meeting of the Section of Child Psychiatry, Royal Australian and New Zealand College of Psychiatrists, Sydney, Australia, April 1980.
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Parental death in childhood and risk of adult depressive disorders: a review. Psychological Medicine 10:289-299, 1980.
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