Bereavement: Reactions, Consequences, and Care (1984)

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Bereavement During Childhood an c] Adolescence

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. Then vulnerability may be exacerbated by survivors who, because of they own bereavement, may not be able to provide sufficient comfort and support.

CHAPTER 5 Bereavement During Childhood and Adolescence jet is not clear exactly how many young people are affected by the death of an immediate family member. Kliman82 estimates that 5 percent of children in the United States I.5 million lose one or both parents by age IS; others suggest that the pro- portion is substantially higher in lower socioeconomic groups. This chapter discusses the types of bereavements considered to have the most serious implications for medical, psychiatric, and behavioral se- quelae in children-namely, death of a parent or sibling. Because more of the literature in this field deals with parental than with sibling loss and because many of the reactions to both types of bereavement over- lap, most of the discussion is based on studies of response to the death of a parent. 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 im- pact of trauma in children depends so heavily on the life stage during This chapter was prepared by Janice L. Krupnick, M.S.W., consultant, supported in part by the Kenworthy-Swift Foundation, New York. Background materials and assis- tance were provided by committee members Gerald Koocher, Ph.D., and Theodore Sha- piro, M.D., and by Fredric Solomon, M.D. 99

100 / Bereavement: Reactions, Consequences, and Care which the event occurs, this chapter is informed by a particular empha- sis on developmental analysis. This perspective assumes that the reper- cussions and meanings of major object loss will be colored by the indi- vidual child's level of development. 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, es- pecially depression, frequently reveal childhood bereavement, suggest- ing that such loss may precipitate or contribute to the development of a variety of psychiatric disorders and that this experience con render a per- son emotionally vulnerable for life. This special vulnerability of chil- dren is attributed to developmental immaturity and insufficiently de- veloped coping capacities. The tendency to impose adult models on children has generally led to a great deal of confusion and misunderstanding about children's griev- ing. Although sharing some similarities with adults and even with mon- keys {see Chapter A, children's reactions to Toss do not look exactly like adults' reactions, either in their specific manifestations or in their dura- lion. For example, often what seems glib and unemotional in the small child such as telling every visitor or stranger on the street, "my sister died"-is the child's way of seeking support and observing others to gauge how he or she should feel. Children may be observed playing games in which the death or funeral activities are reenacted in an effort to master the loss. A child may ask the same questions about the death over and over again, not so much for the factual value of the information as for reassurance that the story has not changed. A four- or five-year-old might resume playing following a death as if nothing distressing had happened. Such behavior reflects the cognitive and emotional capacity of the child and does not mean that the death had no impact. Losses are so painful and frightening that many young children-able to endure strong emotions for only brief periods alternately approach and avoid their feelings so as not to be overwhelmed. Because these emotions may be expressed as angry outbursts or misbehavior, rather than as sadness, they may not be recognized as grief-related. Further- more, because their needs to be cared for and related to are intense and immediate, young children typically move from grief reactions to a prompt search for and acceptance of replacement persons. Unlike adults who con sustain a year or more of intense grieving, children are likely to manifest grief-related affects and behavior, on an intermittent basis, for many years after loss occurs; various powerful reactions to the loss r~or- mally will be revived, reviewed and worked through repeatedly at suc- cessive levels of subsequent development. Thus, ~ dealing with chil

Childhood and Adolescence / 101 dren who have sustained a loss it is important to be aware of the special nature of grieving in children and not to expect that they will express their emotions like adults or that their overt behaviors will necessarily reveal their internal distress. As noted later in this chapter, the delayed working through of bereavement may require specialized assistance if development seems blocked or psychopathologic symptoms appear.83 In order for complete "mourning" to occur in the true psychoanalytic sense of detaching memories and hopes from the dead person,5i 52 the child must have some understanding of the concept of death, be capable of forming a real attachment bond, and have a mental representation of the attachment figure. Although there is no doubt that even very young children react to Toss, there is considerable controversy about when children have the developmental prerequisites for complete "mourn- ing" and about the likelihood of achieving a healthy outcome if bereave- ment occurs prior to this time. Generally it is agreed that prior to age 3 or 4 children are not able to achieve complete mourning and it is agreed that by adolescence youngsters can mourn (but are still more vulnerable than adults because they are experiencing so many other losses and changes). The controversy centers on the years in between: can a healthy resolution be achieved and how similar are children's and adults' bereavement reactions? A number of studies have been conducted in recent years {e.g., Anthony,5 Bluebond-Langer,23 Gibney,58 Kane, 79 Koocher,84 Menig- Peterson and McCabe,99 Piaget,~07 Pitcher and Prelinger,~°8 Spinetta,~32 Talimer et al.i35) to dete' ~ Paine how children at various ages comprehend death. A fairly standard view was put forth by Nagy~04 in 1948. Analyzing the words and drawings of a relatively large sample {378J of Hungarian chil- dren who had been exposed to considerable trauma and death in the pre- ceding few years, she conceptualized a three-stage model of awareness and linked the stages to approximate chronological ages. Prior to about three years of age, children's cognitive and language development is ton immn1:llre for the.., to ha anal rmnrPT~t mI Arch ~ ~ W ^~ ~ _ ~ ~ ~ ~ ~ ~ ~ ~r ~ vat ~-CL ~ ~ . ~ . . _ . . According to Nagy's stage 1 |roughly ages 3-5J, death is seen as revers- ible; the dead are simply considered "less alive," in a state analogous to steep. Young children functioning at what Piageti07 termed the "pre- operational" level of development will not generally recognize the irre- versibility of death.84 86 95 In stage 2 {ages 5-9J, children begin to com- prehend the finality of death, but believe that it happens only to other people. In the third stage {after age TOJ, the causes of death can be under- stood, and death is perceived as final, inevitable, and associated with the cessation of bodily activities. As is true in all child development,

102 / Bereavement: Reactions, Consequences, and Care there is considerable age variation in attainment of the different stages and children may regress when emotionally threatened. Prior to about six months of age, infants fait to respond to separation from their mothers because they have not yet developed the capacity for memory of a specific personal relationship.33 The development of stran- ger anxiety, occurring at about six to eight months, signifies that an in- fant has established a true object relationship with its mother or pri- mary caretaking figure. This reaction suggests that an infant is developmentally capable of retaining memory traces of his mother and is capable of responding to her absence with displeasure~33 and depres- sion.40 However, it is not until three or four years of age that a child has a coherent mental representation of important attachment figures and has achieved object constancy. Observational studies of children between about four years of age and adolescence have led psychiatrists to conflicting conclusions about the nature of children's grieving and about their ability to achieve a healthy outcome. Some psychoanalysts3 42 75 i42 ~43 maintain that it is not until adolescence that children have the capacity to tolerate the strong pain- fuT affects necessary for completing the separation process and that chil- dren are more likely to use immature defense mechanisms, such as de- nial, that interfere with adequate resolution of Toss. Thus these observers view children's reactions to Toss as qualitatively different from adult reactions. Others believe that after object constancy has been achieved {at three to four years of age), bereavement need not necessarily lead to enduring psychopathology. Increasingly, it is being recognized27 55 8~ that if the child has a consistent adult who reliably satisfies reality needs and en- courages the expression of feelings about the Toss, healthy adjustment can occur. Furthermore, the biologic unfolding inherent in develop- ment naturally pushes children toward increasing cognitive and emo- tional maturity. This "developmental push" is seen as an asset that contributes to children's potential resiliency under favorable circum- stances. Some psychiatrists, most notably Bow~by,24 emphasize the similari- ties between adults' and children's responses to Toss and see an evolu- tionary basis for them. In Bow~by's view, the argument about children's capacity for "mourning" is in large part terminological, with many psy- choanalysts restricting the use of "mourning" to psychological proc- esses 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

Childhood and Adolescence / 103 Kliman suggested at one of the committee's site visits that perhaps too much concern has focused on this debate. In his opinion it would be more fruitful to have a detailed understanding of the bereavement pro- cess in children so that those who interact with children can be most responsive and helpful. METHODOLOGICAL ISSUES Most of the literature on bereavement in childhood is based on obser- vations of disturbed children who are in psychotherapeutic or psy- choanalytic treatment.~°° These case reports offer valuable clinical in- formation 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 individ- ual 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 in- formation. In addition, relatively few use control groups, making it im- cossible to know what the. base rates of particular behaviors or svmo tome might be in the general population. Where controls are used' it is often unclear whether they are matched for age and sex. Most of the data on very early (below the age of five) childhood loss are not specific to bereavement but are based on observations of institu- tionalized children (e.g., Bowlby24-26) who were temporarily separated from parents. It is not clear if the children's resnonse.s in there. ~t~ldi~ 1 ~ . ~ ~ . ~ r wc;~c ua~cu o~ parenra' loss Poseur, on one multiple other losses associ- ated with removal from the home environment, or the unfamiliar and sometimes chaotic circumstances associated with institutional place- ment. Because these children were not followed over a very long period of time, neither is it known whether pathologic or disturbing reactions endured. Studies of the long-term effects of bereavement during childhood are abundant, but they are highly controversial because they almost always rely on retrospective data isee Gregory63 for a discussion). In addition these studies often fail to consider the impact of intervening life events, rely too heavily on data based on patients' memories. and use ina~nro- priate control groups. · t ~ ~ ~~= Or - ~ A handful of prospective studies describe intermediate effects' but many of these have methodologic flaws, such as a failure to use non- bereaved control groups'78 ii4 a lack of direct assessment of bereaved children,~37 and a failure to follow children over a sufficiently long pe

104 / Bereavement: Reactions, Consequences, and Care riod of time.~4 i37 Furthermore, it is not clear that findings from studies conducted in other countries, possibly during wartime, can be general- ized to American children living under less socially disruptive condi- tions. Different methods have been used to study outcomes of child- hood bereavement and, partly because of the variation in approach, studies have yielded different results. Few studies provide precise definitions of key terms, such as "depres- sion, " " exaggerated responses, " "pathologic grief, " " anger, " and " sad- ness," so it is difficult to know whether all authors are referring to the same specific reactions. Studies on childhood loss tend to rely exclu- sively on interview data OT material in case files; standardized instru- ments that permit greater generalization across studies have rarely been used in the assessment of children. In fact, such instruments have only begun to be developed in the past few years. It should be noted that, because of the way this chapter is organized, a number of studies are cited several times, perhaps giving the impression that there are more empirical data than is really the case. OUTCOMES OF CHILDHOOD BEREAVEMENT The death of a parent during childhood has been linked with a wide range of serious and enduring health consequences ranging from schizo- phrenia to major depression and suicide {see Table ~ for a summary of key f=dings from each of the major studied. The particular symptoms and syndromes associated with childhood bereavement are generally considered in terms of the immediate reactions that occur in the weeks and months following the death, the intermediate reactions that can ap- pear later in childhood or adolescence, and the Jong-range or "sleeper" effects that may appear in adulthood either as enduring consequences or delayed reactions to the loss. Although these Tong-range effects are of most concern, the research evidence in this area is probably the weakest. Immediate Reactions Children, like adults, experience a range of emotional and behavioral reactions immediately following parental or sibling death. 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 distur- bances, withdrawal, concentration difficulties, dependency, regression, restlessness, and learning difficulties. They also note that initial symp

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Childhood and Adolescence / 111 tom patterns depend largely on the age at which the child is bereaved. For example, children under age five are likely to respond with eating, sleeping, and bowel and bladder disturbances; those under age two may show loss of speech or diffuse distress. School-age children may become phobic or hypochondriacal, withdrawn, or excessively care-giving. Dis- plays of aggression may be observed in place of sadness, especially in boys who have difficulty in expressing longing. Adolescents may re- spond more like adults, but they may also be reluctant about expressing their emotions because of fear that they will appear different or abnor- mal.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. Meccas Consequences. A few investigators have suggested a link between loss experiences and subsequent precipitation or "activation" of specific diseases, such as thyrotoxicosis, rheumatoid arthritis, and diabetes.68 90 ~0~ The literature on the medical consequences of bereave- ment in children is extremely limited, however. Some studies found increased physical symptoms, especially abdomi- nal pain. In a community sample of Israeli children who had lost their fathers, no objective findings about these physical symptoms were es- tablished and the investigators concluded that the responses were largely attention-seeking.78 Van Eerdewegh et al. i37 found no increase in physician visits despite the reported increase in symptoms, possibly suggesting that grieving parents were too preoccupied with their own distress to seek help for their children. Psychiatric Consequences. A number of psychological symptoms, most prominently neurosis and depression, appear to correlate with pa- rental or sibling death. Signs of continuing emotional distress have been noted in both community and patient samples of children who lost a parent or sibling. Kaffman and Elizur45 77 found that about 40% of normal preadolescent Israeli kibbutz children who lost a father during the Yom Kippur War of 1973 continued to show severe maladaptive behavior more than three years following the death. Behavioral problems, amounting to an aver- age of nine handicapping problems per child (e.g., soiling, social isola- tion, learning problems), peaked in the second year after the father's death; these represented a significant increase over prebereavement be havior. Three and a half years after the loss, 65 percent of the total clini- cal symptoms persisted atop medium to severe {ever. Assessing the chil

112 / Bereavement: Reactions, Consequences, and Care dren at 6, IS, and 42 months postbereavement, the authors found that nearly 70 percent of the children showed signs of severe emotional dis- turbance in at least one follow-up period. Fewer than one-third had achieved satisfactory family, school, and social adjustment throughout the entire three and a half years of the study. A subsequent study of this sampled suggested that children with preexisting emotional difficulties and those who came from families marked by marital discord were at greater risk for more severe pathologic developments than were chil- dren from stable families with no prior emotional problems. An unevenness in the development of bereavement reactions among these Israeli children was noted. Although those with symptoms of marked emotional impairment during the early months of bereavement appeared to develop the most severe and prolonged type of pathologic grieving, others revealed no special pathology during the early months but deteriorated emotionally during the second to fourth years. Thus, the timing of severe and persistent clinical symptoms that significantly impaired the child's psychosocial functioning varied in onset and dura tion. 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, per- sisting 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 set- ting and the perceived less central role of the parents did not protect the youngsters from stress. Thus, while the father within a kibbutz is nei- ther the family provider nor principal supplier of material needs, he is still a central attachment figure in his child's emotional life. These find- ings highlight the importance of the psychological meaning of parental loss and its impact on a child. Such findings In general community samples are echoed in studies of psychiatric patients. Studies by both Rutteri26 and Arthur and Kemme7 found neurotic illness was excessive in disturbed children who had lost a parent. The latter found that 52 percent of their sample were experi- encing autonomy conflicts, 27 percent felt panicky over relationships and dependent on others, and 39 percent had problems in defining their relationship with the opposite-sex parent four months to two years after parental loss.

Childhood and Adolescence / 113 In a sample of disturbed 22- to 14-year-olds who had lost a sibling,36 guilt reactions, accompanied by trembling, crying, or sadness, were present in half the subjects and evident for five or more years after the death. Forty percent had prolonged or anniversary hysterical identifica- tion with the dead sibling's prominent symptoms. A striking finding of both Van Eerdewegh et al. ]37 and Rutteri26 in En- glish psychiatric clinic samples is the high frequency of depression in adolescent boys who lost a father through death. 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 precipi- tate a depressive disorder in adolescents already at risk for manic- depressive disorder of the depressive type. Behavioral Consequences. There is general agreement among cTini- cians that parental bereavement has an adverse impact on school func- tioning, both in academic performance and social behavior. Several studies of Australian, Israeli, and American children 13 months to 6 years postbereavement showed evidence of examination failure, school refusal, a decreased interest in school activities, and drop-out.20~93~5~37 These findings parallel the general finding that school performance is very often a significant indicator of emotional difficulty. Delinquency has been found to correlate with parental bereavement, particularly in adolescents.64~5 i26 In a controlled follow-up study of a sample of 264 Minnesota school children who had lost a parent, Greg- ory64 found that bereaved adolescents who lived with an opposite-sex parent had higher rates of delinquency than controls. Raphaeliis notes that loss generates longing for comforting and reas . . ~ ~ - i, surance In girls, leading to sexuai~zec reiat~onsn~ps that provide a sense of ego fusion with another, whereas boys are more likely to engage in petty theft, car-stealing, fights, drug-taking, or testing of authority systems. Long-Term (Delayed) Effects A number of researchers have conducted retrospective studies to in- vestigate a hypothesized link between childhood bereavement and vul- nerability during adulthood to a variety of serious disorders, including neurosis, psychosis, physical illness, depression, schizophrenia, and an- tisocial behavior. Specific findings from these studies are contradictory, but they generally point to an increased vulnerability to physical and

114 / Bereavement: Reactions, Consequences, and Care mental illness later in life. Findings from the one prospective study con- ducted by Fulton and his colleagues ]2~96 also suggest that bereaved chiT- dren suffer long-term vuInerabilities. Meccas Consequences. . .. . Raphaellls points to a number of retrospec tive studies suggesting that persons who have experienced such loss are more likely to demonstrate symptomatology, increased health care utilization, and complaints of ill health in adult life. She cites Seligman et al.,~28 who link early parental death with increased use of medical service by adolescents, and Schmale and Iker,~27 who found a possible association between childhood loss and development of cancer, al- though (as discussed in Chapter 2) the connection has not been clearly demonstrated. Bendikson and Fulton's prospective study of a cohort of 264 caren , ,, .. . . . . ~ fatly bereaved Minnesota ninth graders also suggests a possible predis- position to later illness. When these individuals were observed in their thirties they were significantly more susceptible to serious medical ill- nesses than the control subjects, and experienced significantly more emotional distress. Unfortunately, the exact nature of the illnesses and distress was not specified. Psychiatric Consequences. Substantially more work has been done on the possible association between early Toss and mental illness, with the majority of investigators reporting a positive relationship between childhood bereavement and adult-life mental illness. Most of these re- searchers 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 at- tempt to further specify risk factors in terms of the sex of the deceased parent and the age and sex of the bereaved child. The evidence is contradictory, but many investigators find a signifi- cant increase of both neurosisii9 and psychosis9 in persons who experi- enced early bereavement when compared with controls. Links are sug- gested between early loss and adult-life impairment in sexual identity, development of autonomy, and capacity for intimacy.6 28 ~9 The chief disagreement is over which combination of variables puts a subject at most risk. For example, Barry and I,indemann~° found that girls who lose a mother between birth and age 2 are at greatest risk for neurosis whereas in Norton's sample, loss of the father before age 10 was most . ... slgnlilcant. Recent studies suggest that sample characteristics may influence ap- parent outcome. For example, in a 1972 study comparing 500 Scottish psychiatric hospital admissions with a control group of general practice patients matched for age and sex, Birtchnelli7 found that Toss of the

Childhood and Adolescence / 115 mother before age 10 was an etiologic factor in the subsequent develop- ment of mental illness. This finding was not replicated in his later work, however, which drew upon a community sample. Individuals who lose a parent or sibling in childhood have been con- sidered to be most at risk for subsequent depressive disorders. Based on his clinical observations, Bow~by27 concludes that profound early loss renders people highly vulnerable to subsequent depressive disorders, with each subsequent Toss triggering an upsurge of unresolved grief ini- tially related to the early bereavement. Research data examining the link between early loss and adult depres- sion 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 ~ ~ stud- ies29 3i 38 4i 49 72 i03 i2s reported significant increases in depressive disor- ders among the bereaved group; childhood loss of a parent increased the risk of depression by a factor of two or three. In addition, in seven out of eight controlled studies,ii is 3) 57 i02 i29 ]4i early loss was correlated with severity of depression. Parentally bereaved subjects were more likely to experience psychotic- rather than neurotic-level depression.3i i4i In one well-controlled study, Brown et al.3i found that the incidence of maternal death prior to age ~ ~ was significantly more frequent for de- pressed women in a community sample than for matched, nondepressed controls. They also found that 66 percent of those diagnosed as psychoti- cally depressed had a history of early loss compared with only 39 percent of the neurotic depressives. There is also some suggestion that depres- sions associated with early bereavement tend to be reactively rather than endogenous; studies that have included the more biologically predis- posed bipolar {manic-depressive) disorders typically have not estab- lished a connection between them and early bereavement. i 73 i09 A number of studies show a link between childhood bereavement and suicide attempts in adult life (e.g., Birtchnell, i6 Dorpat et al. ,44 Farberow and Simon,47 Greer,62 Hil1,7i Levi et al.9~. Birtchnell found that twice as many depressed suicide attempters were parentally bereaved compared with nonsuicidal depressives (66.7 percent versus 33.3 percent!. Tennant et al.,~36 in a recent review of studies regarding parental death in childhood and later risk for depression, caution that the data are not conclusive. Birtchnell~8 suggests that additional factors, such as the quality of the relationship with subsequent caretakers, may be more influential in determining risk for later depression than simply the ex- perience of bereavement in and of itself. Evidence regarding bereavement as an etiologic factor in the develop- ment of schizophrenia is less convincing than that on depression. Den- nehy,4~ Hilgard,69 and Rosenzweig and Brayi24 report positive findings,

116 / Bereavement: Reactions, Consequences, and Care while Granville-Grossman6i and Gregory6s find no significant correla- tion. Behavioral Consequences. Research findings are suggestive of a link between childhood loss and subsequent criminality. In Markesun and Fulton's prospective community study, 96 men who had been bereaved in childhood had more offenses against the law when in their twenties than did controls. In samples of both mate and female prisoners30 32 the histories revealed an excess of parental death; the "affectionless crimi- nal" appears to be most strongly represented. Based on clinical observations of psychotherapy patients of the Barr- Harris Center for the Study of Separation and Loss During Childhood, in Chicago, AltschuT and Beiser4 have noted difficulties in parenting when the bereaved child grows up and has children of his or her own. 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 identifi- cations 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 suffer- ing if they die. Conclusions About Outcomes It is difficult to draw conclusions about the Tong-term consequences of bereavement during childhood or adolescence. The data suggest po- tential difficulties, but there is a lack of specificity regarding what places a bereaved youth at risk. Conceming intermediate-term consequences, the existing literature suggests that early bereavement greatly increases a child's susceptibil- ity to depression, school dysfunction, and delinquency. Given the im- maturity of the chi1d's personality, it seems likely that even a minor depression of 13 months' duration might inhibit or interfere with nor- mal ego development, thereby disrupting or distorting psychological growth. 137 THE GRIEVING PROCESS IN CHILDREN As discussed earlier in this chapter, the nature of children's reactions to Toss will depend largely on their stage of emotional and cognitive de- velopment. Although specific manifestations of distress and the dura

Childhood and Adolescence / 117 lion of responses vary by age and by individual, children {like adults) have been observed to go through a relatively predictable series of phases of bereavement responses. Based on his observations of young children in a residential nursery who were separated from matemal figures, Bow~by24-27 identified three sequential phases in response to separation and Toss. When a healthy child over the age of six months was taken from his mother, a period of "protest" ensued, characterized by loud, angry, tearful behavior sug- gesting an expectation of and demand for reunion. This stage might last for as Tong as a week or more. When attempts at reunion failed to pro- duce the desired results, a phase of '`despair" set in, marked by acute pain, misery, and a sense of diminishing hope. Following this came the final stage of "detachment," during which children behaved as if they no longer cared whether or not their mothers returned; upon actual re- union, their initial reaction might be to continue avoidance behavior and withdrawal. Elizur and Kaffman's work45 with kibbutz children described the course of grieving during the first four years following paternal bereave- ment. The immediate reaction was one of pain and grief. During the first year, the children began to examine the meanings and implications of the loss and to ask realistic questions to gain understanding of "dead" and "alive." During the second year, children were generally more understanding and accepting of the loss and defensive maneuvers decreased, but they showed a significant increase in anxiety. In order to cope, they became more dependent on their mothers and were more de- manding; aggressive behavior, discipline problems, and restlessness in- tensified. During the third and fourth years, manifestations of overde- pendence still characterized two-thirds of the sample, but anxiety level and augmented aggressiveness were reduced. Despite a general trend to- ward 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 follow- ing bereavement relates to negative shifts in self-concepts and self- esteem. Rochlin~20-~22 and Kliman83 have observed that children often assess themselves more negatively after a parent's death than before. Children who interpret a parent's death as desertion because the parent did not love them may believe that they are unlovable, which may result in a persistent sense of low self-esteem.37

118 / Bereavement: Reactions, Consequences, and Care Following a major relationship loss, a child may see himself as help- less and vulnerable. It is possible that this image of being frighteningly small and helpless is the most disruptive and disorganizing view of the self that can emerge subsequent to parental death. Based on their exten- sive clinical experience with bereaved children, Erna Furman54 and Rob- ert Furman56 have observed that while there is a fairly universal ten- dency toward self-blame following bereavement, it may be that the re- sultant 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. The sense of being ineffectual in controlling life events impinging on the self may lead to a kind of passivity, apathy, and depression, similar to the mental state described by Seligman in his theory of "learned helpless- ness" as the precursor of depression. Alternatively, a bereaved child may regard himself as hostile and de- structive. The tendency of children to think in egocentric, magical ways and to equate thought with deed may lead to the belief that their destructive impulses or angry feelings destroyed the parent or sibling. This can lead to a hostile image of the self, especially if there was a great deal of competition and hostility in the prior relationship, as is likely to be true of siblings.22 Relatively universal death wishes can return to haunt the bereaved child in the form of feelings of responsibility and guilt. i39 Such feelings are more likely to be a problem if the death wishes were especially intense. The Role of identification in Grieving Identification with a deceased person has been described as more common and dramatic in children than in adults.~3 This process may represent both an unconscious defense mechanism Any a conscious at- tempt to emulate the good qualities of the deceased. 76 If done in modera- tion, such identifications can be enriching for a child.74 83 Taken to an extreme, however, identification with a dead parent can become very frightening, as it can imply adoption of the parent's symptoms and death. Because of this fear, Wolfensteini43 believes that genuinely adap- tive identifications in children are rare. Johnson and Rosenblatt76 have noted that a socially inappropriate identification with a deceased parent may be an expression of incom- plete or pathologic grief. If a child identifies too closely with adults, peers may be rejecting or critical, with a resulting loss of social sup- ports. In addition, when such replacement roles are fostered by adults

Childhood and Adolescence / 119 they can be felt as rather frightening pressure by the child. For example, if a new widow tells her young son that he is now "the man of the house," he may fee! some literal responsibility and become anxious at the prospect of having to assume all the roles of the deceased parent {e.g., surrogate marriage partner or emotional confidant to a depressed adult). If his mother later remarries, the stress on the little "man of the house" is magnified by the fact that she has chosen to "replace" him. Likewise, a child may attempt to replace a deceased sibling as a means to help the parents) cope with loss feelings, thereby compromis- ing the youngster's own identity development. Too often the tendency to idealize the dead also makes it difficult for surviving siblings to deal with their anger at the deceased or at their parents {e.g., for not prevent- ing the death or for seeming to care more about the deceased child). This too may form a basis for overidentification, if the child attempts to se- cure affection by adopting the traits of the deceased. 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. . ... _ , , , ~ There are at least three questions, whether directly articulated or not, anal wade occur to most children following a loss: Did ~ cause this to happen? Will it happen to me? Who will take care of me now for if some- thing happens to my surviving caretaker)? It is important to provide an- swers to these questions and to hear how the child understands those answers, because misunderstandings may give rise to feelings of anger or fear. Perceptions that the parent or sibling's death was a deliberate aban- donment, associated with feelings of rage, tend to undermine ~ chiLl'c ~ _ ~1~ ~ _ 1 _ rat · ~ ~ . . ovary needed sense or Being cared tor. ~ hits was indeed the reaction of 20 percent of the ~arentaliv bereaved Stint. .ct,,rli~1 he Arthur And Kemme.7 ~_ ~ ~, _ -~ ~ ~ ~ ~ Worries that a dead parent might return and seek revenge, 7 concerns that what happened to the deceased parent or sibling could also happen to them or to surviving family members or caretakers, and worries that their basic physical needs for survival may not be satisfiedS3 80 have all been observed. Bow~by27 notes that fears about whom death may claim next may underlie anxious clinging or obstinate behavior. The belief that the world is a safe, predictable place may be destroyed, resulting in disruption of a child's capacity for basic trust.7

120 / Bereavement: Reactions, Consequences, and Care Common Defensive Strategies Many of the reactions In bereaved children that have been described- denial, idealization of the dead parent, inhibition or isolation of grief- related affects, identification with the lost parent, displacement are common defensive strategies. Psychoanalytic writers {e.g., Altschul,3 Deutsch,42 Jacobsen, 75 and Shambaugh,~30J, basing their judgments on small numbers of patients, and researchers studying a sample of normal children45 have com- mented on the frequent use of denial, which they believe underlies per- sistent fantasies of reunion with the deceased. Elizur and Kaffman4s found that bereaved children fantasized in an attempt to maintain the illusion that the deceased parent was still nearby. Denial may help ward off painful feelings and a conscious consideration of the loss.~30 Alts- chul,3 observing that such denial may continue indefinitely, feels that it is the emotional significance of the deceased person that is denied more than the reality of the death. Wolfenstein~42 has commented on a defen- sive band often maladaptive) splitting of the ego in bereaved children that allows them to acknowledge a parent's death as a reality while si- multaneously denying its finality. She suggests that the good moods that may be observed in bereaved children following parental death rep- resent an affective counterpart of denial. When depressed moods occur, particularly in adolescents, they are usually isolated from thoughts of the dead parent. A lost parent is often idealized and preserved in fantasy as the good parent while hostility is displaced onto the surviving caretaker, who is then perceived as the bad parent.~°S Arthur and Kemme,7 assessing dis- turbed children, found such idealization particularly marked in girls who resented attempts to intrude on or devalue fantasized relationships with deceased fathers. In their sample, hostility toward the dead parent was denied and pro Acted onto the surviving parent, who was blamed for the father's death. Wolfenstein~42 believes such idealization of the de- ceased and vilification of the surviving parent represent an attempt to undo prior feelings of hostility toward the parent who died. Conclusions About the Grieving Process Although many of the reactions children display in response to a loss are similar to those observed in adults, the time frame and overt process of grieving in young people are clearly different. Because of develop- mental differences in their cognitive abilities and personality struc- tures, children are likely to use more primitive defense mechanisms

Childhood and Adolescence / 121 than adults {e.g., denial and regressions in coping with their Tosses. These differences put children at substantial psychological risk after the death of a family member. Denial that a death has occurred, for exam- ple, may prevent a child from confronting and working through his or her feelings of Toss. Troublesome behaviors and emotions related to the bereavement may emerge months, or even years, later as a child re- works his grief. VARIABLES AFFECTING PROCESSES AND OUTCOMES In addition to psychological defenses, a number of other variables have been identified that affect the grieving process in children. These include age and emotional stability of the child, sex of the deceased and of the bereaved, the nature of the relationship between the child and the deceased, and the nature of social supports following bereavement. Chides Age, Developmental Stage, and Emotional Stability at the Time of Bereavement A number of clinicians and clinical researchers {e.g., Alexander and Adlerstein,2 Bow~by,27 Elizur and Kaffman,46 McConville et al.,98 Rut- ter,~26 Van Eerdewegh et al.~37) report that the impact of relationship loss will be greater when it occurs at certain ages or stages than at oth- ers. Both Rutted and Bow~by27 have found that bereaved children un- der 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. He speculates that children under the age of one or two are less distressed than bereaved older children because there has been less time to develop ties. Early adolescence also appears to be a vulnerable time in terms of sig- nificant relationship loss.2i Rutteri26, Van Eerdewegh et a}.,l37 and Wolfensteini42 found that the severely depressed children in their stud- ies mostly seemed to be adolescent boys who had lost their fathers. In contrast, Hilgard et al. ,70 using retrospective data, noted a number of out- st~ndingly good adjustments among adults whose parental loss came between the ages of 10 and 15, preceded by a satisfactory home life. Elizur and Kaffman's data4546 78 also suggest that although normal children are at risk following bereavement, preexisting emotional diffi- culties, in combination with other antecedent variables, may exacer

122 / Bereavement: Reactions, Consequences, and Care bate symptoms during the early months following loss. Clarification is needed on the kmds of emotional disturbances and troubled family rela- tionships that place children at greater risk. Quality of Preexisting Relation ship with the Deceased As is true of adults, children's reactions to Toss are more difficult to resolve when the prior relationship with the deceased person was marked by high levels of ambivalence or dependence.~5 As noted earlier, hostility toward a deceased parent or sibling may lead to defensive ma- neuvers, such as idealization of the deceased, which non counter to reso- lution and completion of grief. In addition, unlike adults or adolescents who may have a number of close relationships outside the family, a pre- adolescent child Invests love almost exclusively in parental figures.53 The younger the child, the more dependent he is on parents for survival. Thus, preexisting relationship and age may be interacting variables. Sex of Deceased Parent and Bereaved Child Studies of the impact of and interaction between the sex of the de- ceased parent and that of the child have produced interesting but some- what contradictory results. Kliman8i 82 has observed that from about age three onward, while yearning for the dead parent tends to be more overt when the opposite-sex parent dies, special anxieties may develop when the same-sex parent dies, especially if the child begins to fear that he or she must In some way become the "new daddy" or "new mommy" of the family. In clinical samples, Fast and Caine found that boys who lost fathers felt threatened by and therefore tried to avoid positive feelings toward their mothers, while Arthur and Kemme7 found that girls showed a greater tendency to idealize dead fathers. 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 al- though Rutteri27 found significantly higher levels of depression in ado- lescent 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."

Childhood end adolescence / 123 Quality of the Chid's Support System As discussed throughout this report, social support is a modifying variable that can soften trauma. Unfortunately, children's primary source of support is usually the surviving parent, who also has been traumatically affected by the death of a spouse or child. Widows, usually sad and anxious following conjugal bereavement, of- ten 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 fre- quently experienced multiple life-style changes in the context of make- shift arrangements following the death, with a few being placed in insti- tutions. Rather than the atmosphere of stability and consistency necessary for a better outcome, 53 the common situation following a pa- rental death may be considerable chaos, disorganization, and a sense of insecurity. The level of trauma associated with the Toss of a parent will depend in large part on relationships within the home prior to the parental death and upon the maintenance or reestablishment of the home after the death occurs. Hilgard et al.70 interviewed a representative community sample of 65 adults between the ages of 19 and 49 who had lost a parent through death during childhood. Comparing well-adjusted subjects in the community with selected patients in a mental hospital who had suf- fered childhood parental losses, they identified one protective factor in father loss as being the presence of a reality-oriented, strong mother who worked and kept the home intact, instilling strength in her chil- dren both through her example and through her expectations of their performance. Elizur and Kaffman46 agree that in the case of paternal death, the mother's assertiveness in coping with the loss and the avail- ability of a surrogate father figure influence the course of a child's re- sponses in the years thereafter. Other protective factors include the presence of a mother who can use a network of support outside the home, prebereavement years spent in a home with two compatible parents who had well-defined roles so that early identifications were good, and parental attitudes that fostered in- dependence and a tolerance for separation.46 70 Hilgard et al.70 note that "appropriate" grieving by the surviving parent and avoidance of exces- sive dependency on the children had helped their well-adjusted sample work through the loss and achieve a satisfactory adaptation following parental death.

124 / Bereavement: Reactions, Consequences, and Care In addition to the role of the surviving parent following a death in the immediate family, it would seem that grandparents, aunts and uncles, and perhaps close family friends, could step in to assist the bereaved child. The impact of nonparent figures on the course of children's l~e- reavement reactions has not been documented. Remarriage of the Surviving Parent In a controlled retrospective study of women in a community whose mothers died before they reached age ll, Birtchnell~8 found that only those who experienced poor relationships with mother replacements emerged with major psychological problems. These women tended to manifest neurotic depressions of moderate intensity and were more prone to severe and chronic anxiety symptoms than bereaved women not characterized by such relationships. Fast and Cain48 identified the reluctance of the bereaved child to ac- cept discipline or punishment from the stepparent, competition be- tween 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 relation- ship with the child. They speculate that women this age who have young children have fewer choices of marital partners and may make unsatisfactory compromises. On the other hand, some of the same situations already described as difficult seem to be associated with a parent's failure to remarry. For example, it seems likely that postbereavement bed-sharing, reported by Kliman,8° and the emotional dependency that Hilgard et al.70 find haz- ardous would pose a greater threat to the emotional stability of children when lonely, frightened, unattached parents do not have another adult with whom to share their lives. Cu]tura] Background Although it has been suggested that cultural factors, such as ethnic background, social class, and religion, play a role in determining the child's understanding of and response to Toss, this is an area in which very little research has been done. Based on child interview data, Talimer et al.~35 have concluded that children from lower socioeco- nomic class families are more aware of at least the concept of death, due to the increased amount of violence and death in their social environ

Childhood and Adolescence / 125 meets. In their studies comparing bereaved kibbutz and urban children in Israel, Kaffman and Elizur45 78 found that differences in child-rearing methods, family functioning style, and social setting influenced the type of problems that became prominent following paternal death. Circumstances of the Death The type of death experienced-e.g., anticipated versus unantici- pated, in the home versus in the hospital influences the child's be- reavement response. Erna Furmans3 comments that there are no peace- fu! deaths for parents of young children, and each type of death is associated with particular anxieties; the kinds and sources of anxiety vary with the child and his situation. It is generally agreed that an anticipated death is easier for children to cope with than sudden loss just as it is for adults because forewam- ing seems to provide an opportunity to prepare at least cognitively. If a parent is ill for a prolonged period of time, however, the child often has to deal with knowledge of a series of surgical and medical interventions that may be interpreted as bodily assaults.33 If the particular form of a parentJs or sibling's terminal illness or injury coincides with and gives reality to developmentally appropriate but otherwise transient con- cems, the already existing worries may be intensified and rigidified. Suicide. As discussed in Chapter 4, suicide is generally considered the most difficult type of death to accept. For children, the suicide of a parent or sibling not only presents immediate difficulties, but is thought by many observers to result in life-Ion" vulnerability to mental health problems. Pynoos and his colleagues~2 ii3 have reported on children's immedi- ate reactions to witnessing suicide attempts and homicides. Regardless of what has been told to children, it is clear that they know fundamen- tally 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. In a partially controlled study, Shepherd and Barracloughi3~ followed 36 children {ages 2-17 years) five to seven years after the suicide of a parent and found greater psychiatric morbidity among the suicide survi- vors than among a comparison group. They also noted that prebereave- ment home life was abnormal for these subjects because of the stresses of living with a parent who was mentally ill. In fact, for a few of the children, the suicide was experienced as a relief from a previously "in- supportable situation."

126 / Bereavement: Reactions, Consequences, and Care In their assessment of 45 disturbed children four years after the sui- cide of one parent, Cain and Fast34 found a broad range of psychological symptoms, including psychosomatic disorders, obesity, Funning away, delinquency, fetishism, lack of bowel control, character problems, and neurosis. Compared with other childhood bereavement cases, there was a much higher incidence of psychosis (24 percent versus 9 percent). Common disturbed reactions among this group included a very intense sense of guilt and distortions of communication. As they often receive the message that they should not know or tell about the suicide, these children frequently are in conflict about learning and knowing in gen- eral, with resultant learning disabilities, speech inhibitions, and reality sense disturbances. Parental suicide also appears to be linked with serious Tong-term nega- tive consequences. 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 pre- occupation 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. According to the data of BlachIey et ai.~9 and Farbe- row and Simon,47 there is in fact a far higher than chance incidence of prior suicide in the family backgrounds of individuals who later commit . . , SUlClC .e. Summary of Risk Factors in Childhood Bereavement A review of the clinical and research data suggests that the following factors increase the risk of psychological morbidity following the death of a parent or sibling during childhood years: · Toss occurs at an age below ~ years or during early adolescence, · loss of mother for girls below age ~ ~ and Toss of father for adolescent boys, · psychological difficulties in the child preceding the death Ithe more severe the preexisting pathology, the greater the postbereavement risk), · conflictual relationship with the deceased preceding the death, · psychologically vulnerable surviving parent who is excessively de- pendent on the child, ~ ~ r lack ot adequate family or community supports or parent who can not make use of available support system,

Childhood end adolescence / 127 . . unstable, inconsistent environment, including multiple shifts in caretakers and disruption of familiar routines (transfer to an institu- tional setting would be an extreme example), experience of parental remarriage if there is a negative relationship between the child and the parent replacement figure, · lack of prior knowledge about death, · unanticipated death, and · experience of parent or sibling suicide or homicide. INTERVENTION STRATEGIES Adults often become uneasy when called upon to deal with children on topics of conception, birth, or death. Clinical and research findings suggest that parents often fait to inform their children when a loved one dies, or they do so in an inappropriate or upsetting way, thereby increas- ing the likelihood of further distressing youngsters who are incapable of seeking out the truth for themselves. Although there are no systematic studies assessing the safety and efficacy of different intervention strate- gies, psychological theory and clinical experience do suggest an ap- proach. Anticipating Parental Death When a parent is terminally ill, Erna Furmans3 recommends mainte- nance of personal contact between child and parent for as long as the parent is not drastically altered in appearance or in the ability to com- municate with feeling. She notes that visits should not become an un- bearable burden nor should they force the child to discontinue other ac- tivities. Hilgard et al.70 note that a dying parent can convey to a child an acceptance of death that helps the child to accept its finality. There is some research evidence that short-term professional "pre- ventive therapy" with children of fatally ill parents may also decrease the likelihood of subsequent pathology after a parent dies. In a con- trolled study of normal, randomly assigned children, ages 10-14, Ro- senheim and Ichilov~23 found that brief treatment (10 to 12 weekly home visits) made a significant difference in terms of the anxiety level and social and scholastic adjustment of children who were anticipating parental death. Sessions focused on the child's perception of the par- ent's illness and his or her reactions to it, the factual life situation at home {present, past, and anticipated future!. the child's feelings toward , . . .. . . / . ~. hIS parents, and hIS or her seli-concept. ~ opportunity was provided for catharsis while therapists helped supply realistic perspectives about in

128 / Bereavement: Reactions, Consequences, and Care ner and outer realities {e.g., the resources available to the child in the face of lossJ. Helping Parents to Help Their Children '- ~ The most important preventive intervention may be how parents and others deal with children who have been bereaved. In the interests of helping parents to provide their children with a supportive, understand- ing environment, this section offers some specific suggestions based on information in the literature and on the best judgment of the committee. Providing optimal support to grieving children may be difficult, not only because the parents themselves are extremely upset, but also be- cause they may be uncertain of what to expect from a child. Thus, it is important that parents learn about the grieving process in children so they will know what to expect and will not become alarmed about the differences between childhood and adult grieving. Knowing that the child may ask distressing questions, such as when will there be a new parent or sibling to replace the one who was lost, may eliminate sur- prise and hurt. Such questions do not indicate a shallow attachment to the deceased, but rather the manner in which young children typically respond to Toss. Children may confront strangers with news of the death to test reac- tions and gauge their own responses. They may play "funeral or "under- taker" games for a few days following the death of a family member in order to master the situation. Children may manifest a superficially milder reaction to the loss because of the strong defenses that protect them from becoming flooded with overwhelming emotions. As noted earlier, troubling emotions or behaviors emerging months or years after the death may be related to the bereavement, because children give up their attachment to the deceased much more slowly than adults usually do. Preparing for and understanding such behaviors and coping re- sponses can help avoid or modify reactions of shocked hurt or anger in parents that could intensify the child's feelings of confusion and guilt. 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 chil- dren about death when they axe young, Tong before death is likely to

Childhood and Adolescence / 129 enter their lives in an emotionally threatening way. As Reedits points out, children begin asking questions about death at an early age. They are naturally curious about such phenomena and provide adults with . . Opportunities to intervene. Various educational tools have been suggested. Chaloner,39 Erna Fur- man,54 and Koocher85 recommend using the death of a child's pet or other naturally occurring teaching moment to introduce the concept. Opportunities such as driving past a cemetery or coming across a dead animal while on a nature walk can also be used to provide awareness and understanding, especially that the deceased animal or person will never return. Moreover, it will provide the child with the reassurance that death is not a topic to be avoided with adults. Other means to help children gain awareness about death include children's books See Goldreich60 for a list) and formal death education ciasses.92 When informing a child of a family member's death, a number of vari- ables may be important, including who tells the child, the timing of the information, and the manner in which the child is informed. In most cases, a family's existing belief system will determine what they do. However, families sometimes contact health care profession- als to ask for advice. Professionals need to be cautious in making recom- mendations under these circumstances. Since there is wide cultural an] ~ .. . . family variation, it is important for the health care provider to draw upon his or her knowledge of that family and their culture, taking into consideration the family's own wishes and inclinations. The child's level of social, emotional, and cognitive development, the meaning of the event to the child and family, and the child's fantasies about the death should all be kept in mind when determining what is appropriate for a particular child to be told. When possible decisions .~ho~lcl ho made within the content of ~ Eli with Theo f~mil`7 i38 ~ c, ~ .^ _ . ~.~ ~ . ~ . Use of religious explanations, in particular, is controversial. 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 re- main consistent with the family's values and beliefs. A few basic approaches have been found helpful across most families and cultures. For example, it is generally recommended that a child be told the truth, in simple terms he can understand.39 "Children always observe and sense situations which adults wish and believe they did not see. Invariably, they sense the strained and sinister, and if not helped to

130 / Bereavement: Reactions, Consequences, and Care clarify what they think happened, the adults' silence may increase their fears in fantasy, rather than spare them sorrows." in Telling a child that a parent or sibling is dead and will not lie alive again, and assuring him that the deceased no longer feels anything and is no longer suffering are important elements of a discussion. Encouraging questions is often an effective way to elicit concerns or fears that adults would not have thought might be worrying the child.27 In the case of sudden death, the surviving parent can acknowledge a child's observations and clarify misperceptions or misinterpretations. Specific facts may be added as the child is able to integrate them.53 As is true for adults, it is generally agreed that knowledge helps provide a sense of security. In disturbing situations or crises, feelings of helpless- ness increase with ignorance of the facts. It is relieving for bereaved children to be told that they will not suc- cumb 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 im- portant 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 differ- ence between the self and the deceased. Telling them that neither they nor other surviving family members will die just because of the other death can help the children differentiate reality from fantasy. Children's questions about death may reflect an unexpressed need for reassurance and emotional security rather than a desire for an intellec- tual explanation. For example, it is usually a relief for a bereaved child to hear that he or she was not responsible for the death, if a parent has reason to believe that the child fantasizes culpability. Sensitivity to a child's intents can help him verbalize anxiety, which can then be re- sponded to with understanding. Behind questions about death may be fears that the child will be abandoned or stricken with illness. Under the age of seven, such concerns may be only indirectly communicated. It may be helpful to ask children for a replay of what they have under- stood by saying something like, "Now pretend that one of your friends asks you about this. What would you answer?" By asking specific ques- tions and letting the child reply, the adult can detect and correct mis- conceptions quickly. It may be useful for parents to become aware of potential pitfalls that can emerge following bereavement. For example, parents' capacities to nurture their children may diminish after the death of a family member due to their own grief and loneliness. Because of their own needs during this time, parents may be inclined to turn to their children for emo- tional support. It may feel gratifying to a child to be able to help a dis

Childhood and Adolescence / 131 fraught parent, but this responsibility may also be experienced as fright- ening and overwhelming. Feeling excessive responsibility for a parent can also impede subsequent establishment of autonomy and intimacy with others. Missing the deceased spouse or child, a parent may look for or notice similarities between the deceased and a surviving child, and even com- ment on these similarities, implicitly suggesting that the child should function as a replacement for the person who died. The child's sense of personal worth and value may be compromised by this view of being a replacement for someone else, and such perceptions may result in unre- alistic life plans. 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 develop- ment. Also, holding up the dead child as perfect can have the unin- tended effect of making the surviving one feel that he can never measure up or that he should have died instead. Attending the Funeral Parents frequently express uncertainty about whether children should attend funeral services, fearing that such participation might frighten or otherwise upset them. Most authors who deal with this sub- ject recommend that children be allowed, but not forced, to participate in family mourning and funeral rites if they wish to do so. As with adults, participating in mourning rituals helps children to mark the death and cope with their feelings. Such participation may help children understand the finality of death and aid in dispelling fantasies.66 The parent can help prepare the child for the funeral service by ex- plaining in advance how the room will Took, where they will be sitting, and what they can expect to see and hear. Arranging to have a relative or close family friend sit with the child and be available to leave with him should the child wish to may be helpful. It should be noted, however, that there is great diversity in funerals across cultures and some services might be more difficult for a child to handle than others. Ema Furman53 has observed that even a young child can take in stride some aspects that might otherwise be upsetting as long as the parentis) fee] comfortable with the funeral service. She adds, however, that parents can modify customs to ease the experience for the

132 / Bereavement: Reactions, Consequences, and Care child. For example, arrangements could be made to shorten the service or to have a closed casket. Children should be told in advance if the cas- ket is to remain open, and may be given the opportunity to look at or touch the deceased one last time if they want. Observers agree that it is unwise to insist, however, that a child touch a corpse. In general, by anticipating and addressing all the things a child might see, hear, or have concerns about regarding the funeral procedures, adults may be better prepared to discuss the event in an emotionally supportive manner. A cemetery, for example, may be explained as a pretty and quiet place where people can go whenever they want to be near the dead person's body and remember that individual. Anniversary Reactions: A Norma] Long-Term Consequence As discussed in the preceding chapters on adults, not all long-term consequences of bereavement are pathologic. For example, in a pilot study of bereaved former psychiatric patients, Plotkinii~ found that re- actions to birthdays, holidays, and anniversaries of the death were a nor- mal and predictable part of the grieving process. She argues that such late-occurring manifestations of grief should not be confused with path- ologic grief, and she advocates using such reactions as healthy opportu- nities to express feelings about the death. Johnson and Rosenblatt76 also distinguish between late-occurring "in- complete" or "pathological" grief and the grief that reemerges in chil- dren as a result of maturation and new experience. Sometimes anni- versaries or life marker events provide occasions for the emergence of psychopathologic symptoms for the first time in previously well- adjusted youngsters; but more commonly, quite normal manifestations of grief will recur with such developmentally significant events as com- munion, graduation, pregnancy, or the return to a place an individual previously visited with the deceased parent or sibling. Such feelings may be associated with a conscious realization that the deceased is not present to share the event or they may take place without any under- standing of why the distress has surfaced at that time. The most helpful intervention for this type of grief is supportive assurance that sadness under these circumstances is normal and common among those who have lost a significant person. When to Seek Professional Help As with adults, the distinction between normal and pathologic griev- ing in children is not always clear. Following a loss as profound as the

Childhood and Adolescence / 133 death of a parent or sibling, some behaviors and reactions are to be ex- pected that otherwise might be considered pathologic. In normal child- hood grieving, it is not unusual to see clinical symptoms of emotional disturbance, some regression, denial, and an inability to function. Chil- dren may not report much distress, but their behavior may seem imma- ture for their age. As discussed in earlier chapters, factors such as intensity and duration are usually used to differentiate the normal from pathologic response, but the limits of these descriptors are difficult to establish. A few clini- cians have attempted to delineate some bereavement reactions that sig- nal a need for help. Bow~by's27 warning signals regarding bereaved chil- dren 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, eupho- ria with depersonalization and identification symptoms, and accident proneness. Raphaelii5 categorizes disturbed behaviors in these groups: suppressed or inhibited bereavement responses, distorted grief or mourn- ing (e.g., grief characterized by extreme guilt or anger), and chronic grief, possibly manifested by acting out. In discussions at one of the committee's site visits, Kliman added to this list the inability or unwillingness to speak of the deceased parent, exaggerated cringing to the surviving parent, and expression of only pos- itive or only negative feelings about the deceased. A manifest absence of grief, strong resistance to forming new attachments, complete absorp- tion in daydreaming resulting in a prolonged dysfunction in school, or new stealing or other illegal acts may also be a cry for help.~40 Some clinicians {e.g., Kliman) who take the position that all children who lose a parent through death are "at risk" recommend at least some time-limited intervention in all cases, whether or not a child displays the behaviors cited. From this perspective, each child who loses a signif- icant family member would be assessed periodically as a preventive measure. It is important for parents to be aware of danger signals so that they can know if and when professional help should be sought. Educating parents about normal versus pathologic responses can help them make such decisions. Conclusions About Interventions Although there is little scientific evidence regarding the effect of in- tervention either prior or subsequent to bereavement during childhood,

134 / Bereavement: Reactions, Consequences, and Care there is general agreement that promptness, honesty, and supportive- ness help. Information should be geared to the child's emotional and intellectual level and ample opportunities provided for the child to ask questions about the death. Children need rituals in order to memorial- ize loved ones just as adults do, and should be allowed to participate in funeral or memorial services to the degree to which they feel comfort- able. Although both short- and Tong-term distress should be expected and are normal, some professional mental health intervention conceivably may be useful for all bereaved children, or at least when particular pat- terns of troublesome response become evident. RECOMMENDATIONS FOR FUTURE RESEARCH In order to achieve better understanding of the nature of the bereave- ment process and its potential impact, there is a need for methodologi- cally sound studies in which representative samples of bereaved chil- dren 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? · What conditions foster or inhibit adaptation? · What are the preexisting or concurrent risk factors associated with poor outcomes, including major psychiatric disorder? · How do identified risk factors hold up over the course of the first several years following bereavement? · What is the relationship between the sex of the deceased parent and the age and sex of surviving children on the course of bereavement reac- tions? · How do children who are in various stages of normal cognitive and personality development at the time of bereavement do in comparison with each other and how do they compare with nonbereaved children of the same developmental stage? · How does early loss exert a detrimental impact on children? · How do the effects of bereavement and the process of grieving differ for surviving parents and children? Particular attention should be paid to the design of studies seeking to address questions such as these so that methodological shortcomings do not compromise the conclusions. Grieving children who are not in psy- chotherapy should be directly observed and assessed. Too much empha- sis in the existing literature has been placed on retrospective analysis,

Childhood and Adolescence / 135 memories and extrapolations from adulthood, on parental reports of children's reactions, and on observations of children in treatment who may or may not be representative of grieving children generally. Al- though clinical case studies will continue to provide useful, in-depth information, prospective, clinically sensitive, longitudinal studies of community samples are also needed in order to further current under- standing and resolve controversy about the nature of grieving and the impact of loss on children. 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 mecha- nisms 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. In sum, it is time to move to modern standards of research in the area of childhood bereavement. Young people who have lost a parent or sib- ling through death need to be tracked to determine both short- and long- term consequences of bereavement and to identify subgroups most at risk for pathologic developments. Methods of intervention must be subjected to tests of efficacy to determine how best to help children, with new or modified techniques being particularly designed for the pathologically grieving child. REFERENCES 1. Abrahams, M., and Whitlock, F. Childhood experiences and depression. British [oumal of Psychiatry 1 15: 883-888, 1969. 2. Alexander, I., and Adlerstein, A. Affective responses to the concept of death in a population of children and early adolescents. fournal of Genetic Psychology 93:167-177, 1958. 3. Altschul, S. Denial and ego arrest. [oumal of the American Psychoanalytic Associ- ation 16:301-318, 1968. 4. Altschul, S., and Beiser, H. The effect of parent loss by death in early childhood on the function of parenting. In: Parenthood: A Psychodynamic Perspective {Cohen, R.S., Cohler, B.~., and Weissman, S.H., easy. New York: Guilford Press, 1984. 5. Anthony, S. The Chills Discovery of Death. London: Routledge and Kegan Paul, 1940. 6. Archibald, H., Bell, D., Miller, C., and Tuddenham, R. Bereavement in childhood and adult psychiatric disturbance. Psychosomatic Medicine 4:343-3~1, 1962. 7. Arthur, B., and Kemme, M.L. Bereavement in childhood. [ournal of Child Psy- chologyandPsychiatryS:37-49, 1964.

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