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 disturbances, withdrawal, concentration difficulties, dependency, regression, restlessness, and learning difficulties. They also note that initial symp 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 School-age children may become phobic or hypochondriacal, withdrawn, or excessively care-giving. Displays of aggression may be observed in place of sadness, especially in boys who have difficulty in expressing longing. 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 investigators ^{45,46,81,116,126,137} followed cohorts of parentally bereaved children for one to six years after death. Others (e.g., Lifshitz ⁹³) made single assessments some years after the loss.

Medical 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. ^68,90,101 The literature on the medical consequences of bereavement in children is extremely limited, however.

Some studies found increased physical symptoms, especially abdominal pain. In a community sample of Israeli children who had lost their fathers, no objective findings about these physical symptoms were established and the investigators concluded that the responses were largely attention-seeking. ⁷⁸ Van Eerdewegh et al. ¹³⁷ 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 parental 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 Elizur ^45,77 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 average of nine handicapping problems per child (e.g., soiling, social isolation, learning problems), peaked in the second year after the father's death; these represented a significant increase over prebereavement behavior. Three and a half years after the loss, 65 percent of the total clinical symptoms persisted at a medium to severe level. Assessing the chil dren at 6, 18, and 42 months postbereavement, the authors found that nearly 70 percent of the children showed signs of severe emotional disturbance 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 sample ⁴⁶ 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 children 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 duration.

In a study comparing bereaved kibbutz and urban children, Kaffman and Elizur ⁷⁸ found that 48 percent of the kibbutz children 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") and displayed signs of marked distress, emotional insecurity, and psychological imbalance 18 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. Thus, while the father within a kibbutz is neither the family provider nor principal supplier of material needs, he is still a central attachment figure in his child's emotional life. These findings 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 Rutter ¹²⁶ and Arthur and Kemme ⁷ found neurotic illness was excessive in disturbed children who had lost a parent. The latter found that 52 percent of their sample were experiencing 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.

In a sample of disturbed 2½- 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 identification with the dead sibling's prominent symptoms.

A striking finding of both Van Eerdewegh et al. ¹³⁷ and Rutter ¹²⁶ in English 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. Stone ¹³⁴ suggests that parental death may precipitate a depressive disorder in adolescents already at risk for manicdepressive disorder of the depressive type.

Behavioral Consequences. There is general agreement among clinicians that parental bereavement has an adverse impact on school functioning, 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. ^{20,93,115,137} 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. ^64,115,126 In a controlled follow-up study of a sample of 264 Minnesota school children who had lost a parent, Gregory ⁶⁴ found that bereaved adolescents who lived with an opposite-sex parent had higher rates of delinquency than controls.

Raphael ¹¹⁵ notes that loss generates longing for comforting and reassurance in girls, leading to sexualized relationships 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 investigate a hypothesized link between childhood bereavement and vulnerability during adulthood to a variety of serious disorders, including neurosis, psychosis, physical illness, depression, schizophrenia, and antisocial behavior. Specific findings from these studies are contradictory, but they generally point to an increased vulnerability to physical and mental illness later in life. Findings from the one prospective study conducted by Fulton and his colleagues ^12,96 also suggest that bereaved children suffer long-term vulnerabilities.

Medical Consequences. Raphael ¹¹⁵ points to a number of retrospective 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., ¹²⁸ who link early parental death with increased use of medical service by adolescents, and Schmale and Iker, ¹²⁷ who found a possible association between childhood loss and development of cancer, although (as discussed in Chapter 2) the connection has not been clearly demonstrated.

Bendikson and Fulton's prospective study ¹² of a cohort of 264 parentally bereaved Minnesota ninth graders also suggests a possible predisposition to later illness. When these individuals were observed in their thirties they were significantly more susceptible to serious medical illnesses 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 loss and mental illness, with the majority of investigators reporting a positive relationship between childhood bereavement and adult-life mental illness. 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.

The evidence is contradictory, but many investigators find a significant increase of both neurosis ¹¹⁹ and psychosis ⁹ in persons who experienced early bereavement when compared with controls. Links are suggested between early loss and adult-life impairment in sexual identity, development of autonomy, and capacity for intimacy. ^6,28,119 The chief disagreement is over which combination of variables puts a subject at most risk. For example, Barry and Lindemann ¹⁰ found that girls who lose a mother between birth and age 2 are at greatest risk for neurosis whereas in Norton's ¹⁰⁶ sample, loss of the father before age 10 was most significant.

Recent studies suggest that sample characteristics may influence apparent 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, Birtchnell ¹⁷ found that loss of the mother before age 10 was an etiologic factor in the subsequent development of mental illness. This finding was not replicated in his later work, ¹⁸ however, which drew upon a community sample.

Individuals who lose a parent or sibling in childhood have been considered to be most at risk for subsequent depressive disorders. Based on his clinical observations, Bowlby ²⁷ concludes that profound early loss renders people highly vulnerable to subsequent depressive disorders, with each subsequent loss triggering an upsurge of unresolved grief initially related to the early bereavement.

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, Lloyd ⁹⁴ found that 8 out of 11 studies ^{29,31,38,41,49,72,103,125} 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. In addition, in seven out of eight controlled studies, ^{11,15,31,57,102,129,141} early loss was correlated with severity of depression. Parentally bereaved subjects were more likely to experience psychotic-rather than neurotic-level depression. ^31,141

In one well-controlled study, Brown et al. ³¹ found that the incidence of maternal death prior to age 11 was significantly more frequent for depressed women in a community sample than for matched, nondepressed controls. They also found that 66 percent of those diagnosed as psychotically depressed had a history of early loss compared with only 39 percent of the neurotic depressives. There is also some suggestion that depressions associated with early bereavement tend to be reactive ⁵⁷ rather than endogenous; studies that have included the more biologically predisposed bipolar (manic-depressive) disorders typically have not established a connection between them and early bereavement. ^1,73,109

A number of studies show a link between childhood bereavement and suicide attempts in adult life (e.g., Birtchnell, ¹⁶ Dorpat et al., ⁴⁴ Farberow and Simon, ⁴⁷ Greer, ⁶² Hill, ⁷¹ Levi et al. ⁹¹). 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., ¹³⁶ in a recent review of studies regarding parental death in childhood and later risk for depression, caution that the data are not conclusive. Birtchnell ¹⁸ 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 experience of bereavement in and of itself.

Evidence regarding bereavement as an etiologic factor in the development of schizophrenia is less convincing than that on depression. Dennehy, ⁴¹ Hilgard, ⁶⁹ and Rosenzweig and Bray ¹²⁴ report positive findings, while Granville-Grossman ⁶¹ and Gregory ⁶⁵ find no significant correlation.

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 male and female prisoners ^30,32 the histories revealed an excess of parental death; the ''affectionless criminal" appears to be most strongly represented.

Based on clinical observations of psychotherapy patients of the BarrHarris Center for the Study of Separation and Loss During Childhood, in Chicago, Altschul and Beiser ⁴ 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 identifications with the dead parent and 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.

Conclusions About Outcomes

It is difficult to draw conclusions about the long-term consequences of bereavement during childhood or adolescence. The data suggest potential difficulties, but there is a lack of specificity regarding what places a bereaved youth at risk.

Concerning intermediate-term consequences, the existing literature suggests that early bereavement greatly increases a child's susceptibility to depression, school dysfunction, and delinquency. Given the immaturity of the child's personality, it seems likely that even a minor depression of 13 months' duration might inhibit or interfere with normal ego development, thereby disrupting or distorting psychological growth. ¹³⁷

Shifts in Self-Concepts Following Bereavement

A major area of concern regarding psychological functioning following bereavement relates to negative shifts in self-concepts and selfesteem. Rochlin ^120-122 and Kliman ⁸³ 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

Following a major relationship loss, a child may see himself as helpless 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 extensive clinical experience with bereaved children, Erna Furman ⁵⁴ and Robert Furman ⁵⁶ 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. 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 helplessness" as the precursor of depression. ¹²⁸

Alternatively, a bereaved child may regard himself as hostile and destructive. 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. ^122,139 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. ¹³ This process may represent both an unconscious defense mechanism and a conscious attempt to emulate the good qualities of the deceased. ⁷⁶ If done in moderation, 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, Wolfenstein ¹⁴³ believes that genuinely adaptive identifications in children are rare.

Johnson and Rosenblatt ⁷⁶ have noted that a socially inappropriate identification with a deceased parent may be an expression of incomplete or pathologic grief. If a child identifies too closely with adults, peers may be rejecting or critical, with a resulting loss of social supports. In addition, when such replacement roles are fostered by adults 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 feel 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 parent(s) cope with loss feelings, thereby compromising 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 preventing 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 secure 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 guilt.

There are at least three questions, whether directly articulated or not, that will occur to most children following a loss: Did I cause this to happen? Will it happen to me? Who will take care of me now (or if something happens to my surviving caretaker)? It is important to provide answers 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 abandonment, associated with feelings of rage, tend to undermine a child's badly needed sense of being cared for. This was indeed the reaction of 20 percent of the parentally bereaved patients studied by 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 satisfied ^53,80 have all been observed. Bowlby ²⁷ 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

Common Defensive Strategies

Many of the reactions in bereaved children that have been described— denial, idealization of the dead parent, inhibition or isolation of griefrelated affects, identification with the lost parent, displacement—are common defensive strategies.

Psychoanalytic writers (e.g., Altschul, ³ Deutsch, ⁴² Jacobsen, ⁷⁵ and Shambaugh, ¹³⁰), basing their judgments on small numbers of patients, and researchers studying a sample of normal children ⁴⁵ have commented on the frequent use of denial, which they believe underlies persistent fantasies of reunion with the deceased. Elizur and Kaffman ⁴⁵ 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. ¹³⁰ Altschul, 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 ¹⁴² has commented on a defensive (and often maladaptive) splitting of the ego in bereaved children that allows them to acknowledge a parent's death as a reality while simultaneously denying its finality. 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.

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. ¹⁰⁵ Arthur and Kemme, ⁷ assessing disturbed 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 projected onto the surviving parent, who was blamed for the father's death. Wolfenstein ¹⁴² believes such idealization of the deceased 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 developmental differences in their cognitive abilities and personality structures, children are likely to use more primitive defense mechanisms than adults (e.g., denial and regression) in coping with their losses. These differences put children at substantial psychological risk after the death of a family member. Denial that a death has occurred, for example, may prevent a child from confronting and working through his or her feelings of loss. Troublesome behaviors and emotions related to the bereavement may emerge months, or even years, later as a child reworks his grief. ⁸¹

Child's Age, Developmental Stage, and Emotional Stability at the Time of Bereavement

A number of clinicians and clinical researchers (e.g., Alexander and Adlerstein, ² Bowlby, ²⁷ Elizur and Kaffman, ⁴⁶ McConville et al., ⁹⁸ Rutter, ¹²⁶ Van Eerdewegh et al. ^l37) report that the impact of relationship loss will be greater when it occurs at certain ages or stages than at others. Both Rutter ¹²⁶ and Bowlby ²⁷ have found that bereaved children under the age of five are more susceptible than older children to pathologic outcomes. But whereas Bowlby 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 significant relationship loss. ²¹ Rutter ¹²⁶, Van Eerdewegh et al., ¹³⁷ and Wolfenstein ^l42 found that the severely depressed children in their studies mostly seemed to be adolescent boys who had lost their fathers. In contrast, Hilgard et al., ⁷⁰ using retrospective data, noted a number of outstandingly 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 data ^45,46,78 also suggest that although normal children are at risk following bereavement, preexisting emotional difficulties, in combination with other antecedent variables, may exacer bate symptoms during the early months following loss. Clarification is needed on the kinds of emotional disturbances and troubled family relationships that place children at greater risk.

Quality of Preexisting Relationship with the Deceased

As is true of adults, children's reactions to loss are more difficult to resolve when the prior relationship with the deceased person was marked by high levels of ambivalence or dependence. ¹¹⁵ As noted earlier, hostility toward a deceased parent or sibling may lead to defensive maneuvers, such as idealization of the deceased, which run counter to resolution and completion of grief. In addition, unlike adults or adolescents who may have a number of close relationships outside the family, a preadolescent 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 deceased parent and that of the child have produced interesting but somewhat contradictory results. Kliman ^81,82 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 Cain ⁴⁸ found that boys who lost fathers felt threatened by and therefore tried to avoid positive feelings toward their mothers, while Arthur and Kemme ⁷ 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 samples ³¹ and studies of women psychiatric patients ^14,15,17 suggest that girls are more vulnerable than boys to parental bereavement in general and more vulnerable to loss of a father during adolescence. ^17,21,71

Contrary to the findings cited above, however, Kaffman and Elizur ⁷⁸ found few differences between boys and girls who lost a father, and although Rutter ¹²⁷ 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."

Quality of the Child'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, 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 Rutter ¹²⁶ 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.

The level of trauma associated with the loss 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 suffered 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 children both through her example and through her expectations of their performance. Elizur and Kaffman ⁴⁶ agree that in the case of paternal death, the mother's assertiveness in coping with the loss and the availability of a surrogate father figure influence the course of a child's responses 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 independence and a tolerance for separation. ^46,70 Hilgard et al. ⁷⁰ note that "appropriate" grieving by the surviving parent and avoidance of excessive dependency on the children had helped their well-adjusted sample work through the loss and achieve a satisfactory adaptation following parental death.

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 bereavement 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 11, Birtchnell ¹⁸ 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 Cain ⁴⁸ 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. 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, ⁸⁰ and the emotional dependency that Hilgard et al. ⁷⁰ find hazardous 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.

Cultural 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 loss, this is an area in which very little research has been done. Based on child interview data, Tallmer et al. ¹³⁵ have concluded that children from lower socioeconomic 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 ments. In their studies comparing bereaved kibbutz and urban children in Israel, Kaffman and Elizur ^45,78 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 unanticipated, in the home versus in the hospital—influences the child's bereavement response. Erna Furman ⁵³ comments that there are no peaceful 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 forewarning 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. ⁵³ If the particular form of a parent's or sibling's terminal illness or injury coincides with and gives reality to developmentally appropriate but otherwise transient concerns, 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-long vulnerability to mental health problems.

Pynoos and his colleagues ^112,113 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.

In a partially controlled study, Shepherd and Barraclough ¹³¹ 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 survivors than among a comparison group. They also noted that prebereavement 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 "insupportable situation."

In their assessment of 45 disturbed children four years after the suicide of one parent, Cain and Fast ³⁴ found a broad range of psychological symptoms, including psychosomatic disorders, obesity, running 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 general, with resultant learning disabilities, speech inhibitions, and reality sense disturbances.

Parental suicide also appears to be linked with serious long-term negative consequences. For example, Dorpat, ⁴³ examining the case material of 17 adult psychiatric patients who were seen an average of 16 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 Fast ³⁵ 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 Blachley et al. ¹⁹ and Farberow 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 suicide.

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:

• loss occurs at an age below 5 years or during early adolescence,
• loss of mother for girls below age 11 and loss of father for adolescent boys,
• psychological difficulties in the child preceding the death (the 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 dependent on the child,
• lack of adequate family or community supports or parent who cannot make use of available support system,
• unstable, inconsistent environment, including multiple shifts in caretakers and disruption of familiar routines (transfer to an institutional 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.

Anticipating Parental Death

When a parent is terminally ill, Erna Furman ⁵³ 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. 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 ''preventive therapy" with children of fatally ill parents may also decrease the likelihood of subsequent pathology after a parent dies. In a controlled study of normal, randomly assigned children, ages 10-14, Rosenheim and Ichilov ¹²³ 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 parent'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 self-concept. An opportunity was provided for catharsis while therapists helped supply realistic perspectives about in ner and outer realities (e.g., the resources available to the child in the face of loss).

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, understanding 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 because 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 surprise and hurt. Such questions do not indicate a shallow attachment to the deceased, but rather the manner in which young children typically respond to loss.

Children may confront strangers with news of the death to test reactions and gauge their own responses. They may play "funeral or "undertaker" 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. ⁸¹ Preparing for and understanding such behaviors and coping responses 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 children about death when they are young, long before death is likely to enter their lives in an emotionally threatening way. As Reed ¹¹⁸ 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 Ema Furman, ⁵⁴ and Koocher ⁸⁵ 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 Goldreich ⁶⁰ for a list) and formal death education classes. ⁹²

When informing a child of a family member's death, a number of variables 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 professionals to ask for advice. Professionals need to be cautious in making recommendations under these circumstances. Since there is wide cultural and 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 should be made within the context of a dialogue with the family. ¹³⁸

Use of religious explanations, in particular, is controversial. Some Western observers think that explanations about the deceased going to heaven may be upsetting to children who think and interpret things more concretely than adults. ^66,84,116 Others, however, have remarked on the comfort that religious beliefs can provide following bereavement. ⁹⁷ What is most suitable for a particular child will depend on the factors 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. 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 clarify what they think happened, the adults' silence may increase their fears in fantasy, rather than spare them sorrows." ¹¹⁰ Telling a child that a parent or sibling is dead and will not be 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 helplessness increase with ignorance of the facts.

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. 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 intellectual explanation. ¹¹⁸ 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 intent ⁸⁵ can help him verbalize anxiety, which can then be responded 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 understood by saying something like, "Now pretend that one of your friends asks you about this. What would you answer?" By asking specific questions and letting the child reply, the adult can detect and correct misconceptions 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 emotional support. It may feel gratifying to a child to be able to help a dis traught parent, but this responsibility may also be experienced as frightening 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 comment 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 unrealistic life plans.

Krell and Rabkin ⁸⁷ 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 Corwin ⁶⁷ warn that this need to treasure surviving children can stifle emotional development. Also, holding up the dead child as perfect can have the unintended 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 subject 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 explaining in advance how the room will look, 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. Erna Furman ⁵³ has observed that even a young child can take in stride some aspects that might otherwise be upsetting as long as the parent(s) feel comfortable with the funeral service. She adds, however, that parents can modify customs to ease the experience for the 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 casket 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 Normal 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, Plotkin ¹¹¹ 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.

Johnson and Rosenblatt ⁷⁶ also distinguish between late-occurring " incomplete" or "pathological" grief and the grief that reemerges in children as a result of maturation and new experience. Sometimes anniversaries 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 communion, 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 understanding 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 grieving in children is not always clear. Following a loss as profound as the death of a parent or sibling, some behaviors and reactions are to be expected that otherwise might be considered pathologic. In normal childhood grieving, it is not unusual to see clinical symptoms of emotional disturbance, some regression, denial, and an inability to function. Children may not report much distress, but their behavior may seem immature 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 clinicians have attempted to delineate some bereavement reactions that signal a need for help. Bowlby's ²⁷ warning signals regarding bereaved children include the presence of persistent anxieties (such as fears of further loss or fear that the self will die), 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. Raphael ¹¹⁵ categorizes disturbed behaviors in these groups: suppressed or inhibited bereavement responses, distorted grief or mourning (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 clinging to the surviving parent, and expression of only positive or only negative feelings about the deceased. A manifest absence of grief, strong resistance to forming new attachments, complete absorption in daydreaming resulting in a prolonged dysfunction in school, or new stealing or other illegal acts may also be a cry for help. ¹⁴⁰

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 significant 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 intervention either prior or subsequent to bereavement during childhood, there is general agreement that promptness, honesty, and supportiveness 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 memorialize loved ones just as adults do, and should be allowed to participate in funeral or memorial services to the degree to which they feel comfortable.

Although both short- and long-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 patterns of troublesome response become evident.