NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Institute of Medicine (US) Committee for the Study of Health Consequences of the Stress of Bereavement; Osterweis M, Solomon F, Green M, editors. Bereavement: Reactions, Consequences, and Care. Washington (DC): National Academies Press (US); 1984.

Cover of Bereavement

Bereavement: Reactions, Consequences, and Care.

Show details

CHAPTER 5Bereavement During Childhood and Adolescence

As vividly depicted in the Käthe Kollwitz print entitled Killed in Action, children are especially vulnerable to psychological problems after the death of a parent or sibling

Figure

As vividly depicted in the Käthe Kollwitz print entitled Killed in Action, children are especially vulnerable to psychological problems after the death of a parent or sibling. Their vulnerability may be exacerbated by survivors who, because of (more...)

It is not clear exactly how many young people are affected by the death of an immediate family member. Kliman 82 estimates that 5 percent of children in the United States—1.5 million—lose one or both parents by age 15; others suggest that the proportion 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 sequelae 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 overlap, 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 impact of trauma in children depends so heavily on the life stage during which the event occurs, this chapter is informed by a particular emphasis on developmental analysis. This perspective assumes that the repercussions and meanings of major object loss will be colored by the individual 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, especially depression, frequently reveal childhood bereavement, suggesting that such loss may precipitate or contribute to the development of a variety of psychiatric disorders and that this experience can render a person emotionally vulnerable for life. This special vulnerability of children is attributed to developmental immaturity and insufficiently developed coping capacities.

The tendency to impose adult models on children has generally led to a great deal of confusion and misunderstanding about children's grieving. Although sharing some similarities with adults and even with monkeys (see Chapter 7), children's reactions to loss do not look exactly like adults' reactions, either in their specific manifestations or in their duration.

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. Furthermore, 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 can 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 normally will be revived, reviewed and worked through repeatedly at successive levels of subsequent development. Thus, in dealing with chil 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, 51,52 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 loss, there is considerable controversy about when children have the developmental prerequisites for complete "mourning" and about the likelihood of achieving a healthy outcome if bereavement 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 MenigPeterson and McCabe, 99 Piaget, 107 Pitcher and Prelinger, 108 Spinetta, 132 Tallmer et al. 135 ) to determine how children at various ages comprehend death.

A fairly standard view was put forth by Nagy 104 in 1948. Analyzing the words and drawings of a relatively large sample (378) of Hungarian children who had been exposed to considerable trauma and death in the preceding 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 too immature for them to have any concept of death. According to Nagy's stage 1 (roughly ages 3-5), death is seen as reversible; the dead are simply considered "less alive," in a state analogous to sleep. Young children functioning at what Piaget 107 termed the "preoperational" level of development will not generally recognize the irreversibility of death. 84,86,95 In stage 2 (ages 5-9), children begin to comprehend the finality of death, but believe that it happens only to other people. In the third stage (after age 10), the causes of death can be understood, and death is perceived as final, inevitable, and associated with the cessation of bodily activities. As is true in all child development, 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 fail 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 stranger anxiety, occurring at about six to eight months, signifies that an infant has established a true object relationship with its mother or primary 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 133 and depression. 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 psychoanalysts 3,42,75,142,143 maintain that it is not until adolescence that children have the capacity to tolerate the strong painful affects necessary for completing the separation process and that children are more likely to use immature defense mechanisms, such as denial, that interfere with adequate resolution of loss. Thus these observers view children's reactions to loss 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 recognized 27,55,81 that if the child has a consistent adult who reliably satisfies reality needs and encourages the expression of feelings about the loss, healthy adjustment can occur. Furthermore, the biologic unfolding inherent in development naturally pushes children toward increasing cognitive and emotional maturity. This "developmental push" is seen as an asset that contributes to children's potential resiliency under favorable circumstances.

Some psychiatrists, most notably Bowlby, 24 emphasize the similarities between adults' and children's responses to loss and see an evolutionary basis for them. In Bowlby's view, the argument about children's capacity for "mourning" is in large part terminological, with many psychoanalysts restricting the use of "mourning" to psychological processes with a single outcome—detachment—and others using it more broadly ''to denote a fairly wide array of psychological processes set in train by the loss of a loved person irrespective of outcome." 27

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 process 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 observations of disturbed children who are in psychotherapeutic or psychoanalytic treatment. 100 These case reports offer valuable clinical information regarding psychological symptoms and processes, but it is difficult to know the degree to which these children in treatment are representative of all bereaved children and the extent to which individual reactions may be idiosyncratic.

On the other hand, random samples of bereaved children that provide more methodologically reliable data do not offer the same depth of information. In addition, relatively few use control groups, making it impossible to know what the base rates of particular behaviors or symptoms 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 institutionalized children (e.g., Bowlby 24-26) who were temporarily separated from parents. It is not clear if the children's responses in these studies were based on parental loss itself, on the multiple other losses associated with removal from the home environment, or the unfamiliar and sometimes chaotic circumstances associated with institutional placement. 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 (see Gregory 63 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 inappropriate control groups.

A handful of prospective studies describe intermediate effects, but many of these have methodologic flaws, such as a failure to use nonbereaved control groups, 78,114 a lack of direct assessment of bereaved children, 137 and a failure to follow children over a sufficiently long pe riod of time. 114,137 Furthermore, it is not clear that findings from studies conducted in other countries, possibly during wartime, can be generalized to American children living under less socially disruptive conditions. Different methods have been used to study outcomes of childhood bereavement and, partly because of the variation in approach, studies have yielded different results.

Few studies provide precise definitions of key terms, such as "depression, "exaggerated responses, " "pathologic grief, " "anger, '' and "sadness," so it is difficult to know whether all authors are referring to the same specific reactions. Studies on childhood loss tend to rely exclusively on interview data or material in case files; standardized instruments 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 schizophrenia to major depression and suicide (see Table 1 for a summary of key findings from each of the major studies). 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 appear later in childhood or adolescence, and the long-range or "sleeper" effects that may appear in adulthood either as enduring consequences or delayed reactions to the loss. Although these long-range effects are of most concern, the research evidence in this area is probably the weakest.

TABLE 1. Major Studies of Childhood or Adolescent Bereavement.

TABLE 1

Major Studies of Childhood or Adolescent Bereavement.

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

THE GRIEVING PROCESS IN CHILDREN

As discussed earlier in this chapter, the nature of children's reactions to loss will depend largely on their stage of emotional and cognitive development. Although specific manifestations of distress and the dura tion 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 maternal figures, Bowlby 24-27 identified three sequential phases in response to separation and loss. 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 suggesting an expectation of and demand for reunion. This stage might last for as long as a week or more. When attempts at reunion failed to produce 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 reunion, their initial reaction might be to continue avoidance behavior and withdrawal.

Elizur and Kaffman's work 45 with kibbutz children described the course of grieving during the first four years following paternal bereavement. 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 demanding; aggressive behavior, discipline problems, and restlessness intensified. During the third and fourth years, manifestations of overdependence still characterized two-thirds of the sample, but anxiety level and augmented aggressiveness were reduced. Despite a general trend toward greater adjustment, however, 39 percent of the previously normal sample continued to show signs of emotional distress four years after their fathers had died.

Shifts in 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

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.

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.

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 fail to inform their children when a loved one dies, or they do so in an inappropriate or upsetting way, thereby increasing 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 strategies, psychological theory and clinical experience do suggest an approach.

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.

RECOMMENDATIONS FOR FUTURE RESEARCH

In order to achieve better understanding of the nature of the bereavement process and its potential impact, there is a need for methodologically sound studies in which representative samples of bereaved children are followed for several years and are compared with nonbereaved children. Following are some of the important questions that should be addressed:

  • What are the signs and symptoms of pathologic versus normal grief following parental or sibling death?
  • 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 reactions?
  • 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 psychotherapy should be directly observed and assessed. Too much emphasis in the existing literature has been placed on retrospective analysis, 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. Although 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 understanding 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 mechanisms by which children are helped. Identification of the most effective methods of preventive intervention for particular children or groups of children, and at what stage of life and what distance from the loss these interventions should take place, would add significantly to current knowledge.

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 sibling 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 Journal of Psychiatry 115: 883-888, 1969. [PubMed: 5800322]
2.
Alexander, I., and Adlerstein, A. Affective responses to the concept of death in a population of children and early adolescents. Journal of Genetic Psychology 93: 167-177, 1958. [PubMed: 13587942]
3.
Altschul, S. Denial and ego arrest. Journal of the American Psychoanalytic Association 16: 301-318, 1968. [PubMed: 5654748]
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., editor; , Cohler, B.J., editor; , and Weissman, S.H., editor. , eds.). New York: Guilford Press, 1984.
5.
Anthony, S. The Child's 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: 343-351, 1962. [PubMed: 13862086]
7.
Arthur, B., and Kemme, M.L. Bereavement in childhood. Journal of Child Psychology and Psychiatry 5: 37-49, 1964. [PubMed: 14177074]
8.
Balk, D. Effects of sibling death on teenagers. Journal of School Health 53: 14-18, 1983. [PubMed: 6550148]
9.
Barry, H. Significance of maternal bereavement before the age of eight in psychiatric patients. Archives of Neurology and Psychiatry 62: 630-637, 1949. [PubMed: 15390943]
10.
Barry, H., and Lindemann, E. Critical ages for maternal bereavement in psychoneuroses. Psychosomatic Medicine 22: 166-181, 1960. [PubMed: 13797130]
11.
Beck, A.T., Seshi, B., and Tuthill, R. Childhood bereavement and adult depression. Archives of General Psychiatry 9: 295-302, 1963. [PubMed: 13970047]
12.
Bendiksen, R., and Fulton, R. Death and the child. In: Death and Identity (Fulton, R., editor. , ed.). Baltimore: Charles Press, 1976.
13.
Birtchnell, J. The possible consequences of early parent death. British Journal of Medical Psychology 42: 1-12, 1969. [PubMed: 5785523]
14.
Birtchnell, J. Early parent death and mental illness. British Journal of Psychiatry 116: 281-288, 1970. [PubMed: 5418926]
15.
Birtchnell, J. Depression in relation to early and recent parent death. British Journal of Psychiatry 116: 299-306, 1970. [PubMed: 5418928]
16.
Birtchnell, J. The relationship between attempted suicide, depression, and parent death. British Journal of Psychiatry 116: 307-313, 1970. [PubMed: 5418929]
17.
Birtchnell, J. Early parent death and psychiatric diagnosis. Social Psychiatry 7: 202-210, 1972.
18.
Birtchnell, J. Women whose mothers died in childhood: an outcome study. Psychological Medicine 10: 699-713, 1980. [PubMed: 7208728]
19.
Blachley, P., Wisker, W., and Roduner, G. Suicide by physicians. Bulletin of Suicidology , December: 1-18, 1968.
20.
Black, D. What happens to bereaved children? Proceedings, Royal Society of Medicine 69: 842-844, 1974. [PMC free article: PMC1864697] [PubMed: 1005471]
21.
Black, D. The bereaved child. Journal of Child Psychology and Psychiatry 19: 287292, 1978. [PubMed: 681471]
22.
Blinder, B. Sibling death in childhood. Child Psychiatry and Human Development 2: 169-175, 1972.
23.
Bluebond-Langer, M. The Private Worlds of Dying Children . Princeton, NJ: Princeton University Press, 1978.
24.
Bowlby, J. Grief and mourning in infancy and early childhood. Psychoanalytic Study of the Child 15: 9-52, 1960.
25.
Bowlby, J. Childhood mourning and its implications for psychiatry. American Journal of Psychiatry 118: 481-498, 1961. [PubMed: 13872075]
26.
Bowlby, J. Pathological mourning and childhood mourning. Journal of the American Psychoanalytic Association 11: 500-541, 1963. [PubMed: 14014626]
27.
Bowlby, J. Attachment and Loss. Vol. III: Loss . New York: Basic Books, 1980.
28.
Brown, D. Sex-role development in a changing culture. Psychological Bulletin 54: 232-242, 1958. [PubMed: 13567966]
29.
Brown, F. Depression and childhood bereavement. Journal of Mental Science 107: 754-777, 1961.
30.
Brown, F. Childhood bereavement and subsequent psychiatric disorder. British Journal of Psychiatry 112: 1035-1038, 1966. [PubMed: 5970920]
31.
Brown, G., Harris, L., and Copeland, J. Depression and loss. British Journal of Psychiatry 130: 1-18, 1977. [PubMed: 831901]
32.
Brown, R., and Epps, P. Childhood bereavement and subsequent crime. British Journal of Psychiatry 112: 1043-1048, 1966. [PubMed: 5970921]
33.
Buxbaum, E. Pathological grief reactions in children. Paper presented at the 14th International Congress of Pediatrics, Buenos Aires, Argentina, October 1974.
34.
Cain, A., and Fast, I. Children's disturbed reactions to parent suicide. American Journal of Orthopsychiatry 36: 873-880, 1966. [PubMed: 5971496]
35.
Cain, A., and Fast, I. Children's disturbed reactions to parent suicide: distortions of guilt, communication, and identification. In: Survivors of Suicide (Cain, A., editor. , ed.). Springfield, Ill.: Charles C Thomas, 1972.
36.
Cain, A., Fast, I., and Erickson, M. Children's disturbed reactions to the death of a sibling. American Journal of Orthopsychiatry 34: 741-752, 1964. [PubMed: 14181179]
37.
Call, J., and Wolfenstein, M. Effects on adults of object loss in the first five years. Journal of the American Psychoanalytic Association 24: 659-668, 1976.
38.
Caplan, M., and Douglas, V. Incidence of parental loss in children with depressed mood. Journal of Child Psychology and Psychiatry 10: 225-232, 1969. [PubMed: 5376590]
39.
Chaloner, L. How to answer questions children ask about death. Parent's Magazine, November: 99-102, 1962.
40.
Darwin, C. A biographical sketch of an infant. Mind 2: 285-294, 1877.
41.
Dennehy, C. Childhood bereavement and psychiatric illness. British Journal of Psychiatry 212: 1049-1069, 1966. [PubMed: 5970922]
42.
Deutsch, H. Absence of grief. Psychoanalytic Quarterly 6: 12-22, 1937.
43.
Dorpat, L. Psychological effects of parental suicide on surviving children. In: Survivors of Suicide (Cain, A., editor. , ed.). Springfield, Ill.: Charles C Thomas, 1972.
44.
Dorpat, L., Ripley, H., and Jackson, J. Broken homes and attempted and completed suicides. Archives of General Psychiatry 12: 213-217, 1965. [PubMed: 14237631]
45.
Elizur, E., and Kaffman, M. Children's bereavement reactions following death of the father: II. Journal of the American Academy of Child Psychiatry 21: 474-480, 1982. [PubMed: 7130557]
46.
Elizur, E., and Kaffman, M. Factors influencing the severity of childhood bereavement reactions. American Journal of Orthopsychiatry 53: 668-676, 1983. [PubMed: 6638158]
47.
Farberow, N., and Simon, M. Suicide in Los Angeles and Vienna: an intercultural report. U.S. Public Health Reports 84: 389-403, 1969. [PMC free article: PMC2031547] [PubMed: 4976803]
48.
Fast, I., and Cain, A. The step-parent role: potential for disturbances in family functioning. American Journal of Orthopsychiatry 36: 485-491, 1966. [PubMed: 5910514]
49.
Forrest, A., Fraser, R., and Priest, R. Environmental factors in depressive illness. British Journal of Psychiatry 111: 243-253, 1965. [PubMed: 14288072]
50.
Freud, A. Discussion of Dr. John Bowlby's paper. Psychoanalytic Study of the Child 15: 53-63, 1960. [PubMed: 13701801]
51.
Freud, S. Totem and Taboo (1913). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 13 (Strachey, J., editor. , ed.). London: Hogarth Press and Institute for Psychoanalysis, 1955, pp.1-161.
52.
Freud, S. Mourning and Melancholia (1917). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 14 (Strachey, J., editor. , ed.). London: Hogarth Press and Institute for Psychoanalysis, 1957, pp.237-260.
53.
Furman, E. A Child's Parent Dies . New Haven: Yale University Press, 1974.
54.
Furman, E. Children's Reactions to Object Loss: A Report of The American Psychoanalytic Association. Washington, D.C.: APA, 1978.
55.
Furman, R.A. Death of a six-year-old's mother during his analysis. Psychoanalytic Study of the Child 19: 377-397, 1964.
56.
Furman, R.A. A child's capacity for mourning. In: The Child in His Family: The Impact of Disease and Death (Anthony, E.J., editor; , and Koupernik, C., editor. , eds.). New York: Wiley, 1973.
57.
Gay, M., and Tonge, W. The late effects of loss of parents in childhood. British Journal of Psychiatry 113: 753-759, 1967. [PubMed: 6048365]
58.
Gibney, H. What death means to children. Parent's Magazine , March 1965.
59.
Glick, I., Weiss, R., and Parkes, C. The First Year of Bereavement . New York: Wiley, 1974.
60.
Goldreich, G. What is death? The answers in children's books. Hastings Center Report 7: 10-15, 1977. [PubMed: 873773]
61.
Granville-Grossman, K. Early bereavement and schizophrenia. British Journal of Psychiatry 112: 1027-1034, 1966. [PubMed: 5970919]
62.
Greer, S. Parental loss and attempted suicide: a further report. British Journal of Psychiatry 112: 465-470, 1966.
63.
Gregory, I. Studies of parental deprivation in psychiatric patients. American Journal of Psychiatry 115: 432-442, 1958. [PubMed: 13583245]
64.
Gregory, I. Introspective data following childhood loss of a parent. Archives of General Psychiatry 13: 99-105, 1965. [PubMed: 14314765]
65.
Gregory, I. Retrospective data concerning childhood loss of a parent. Archives of General Psychiatry 15: 354-361, 1966. [PubMed: 5954713]
66.
Grollman, E. Explaining Death to Children . Boston: Beacon Press, 1967.
67.
Hagin, R., and Corwin, C. Bereaved children. Journal of Clinical Child Psychology 3: 39-41, 1974.
68.
Herioch, M., Batson, J., and Baum, J. Psychosocial factors in juvenile rheumatoid arthritis. Arthritis and Rheumatism 21: 229-233, 1978. [PubMed: 637889]
69.
Hilgard, J. Depressive and psychotic states as anniversaries of sibling death in childhood. International Psychiatry Clinics 6: 197-211, 1969. [PubMed: 5810561]
70.
Hilgard, J., Newman, M., and Fisk, J. Strength of adult ego following childhood bereavement. American Journal of Orthopsychiatry 30: 788-799, 1960. [PubMed: 13714235]
71.
Hill, O. The association of childhood bereavement with suicidal attempt in depressive illness. British Journal of Psychiatry 115: 301-304, 1969. [PubMed: 5794123]
72.
Hill, O., and Price, J. Childhood bereavement and adult depression. British Journal of Psychiatry 113: 743-751, 1967. [PubMed: 6048364]
73.
Hopkinson, G., and Reed, G. Bereavement in childhood and depressive psychosis. British Journal of Psychiatry 112: 459-463, 1966.
74.
Jacobson, E. Denial and repression. Journal of the American Psychoanalytic Association 5: 61-92, 1957. [PubMed: 13398327]
75.
Jacobson, E. The return of the lost parent. In: Drives, Affects, Behavior (Schur, M., editor. , ed.). New York: International Universities Press, 1965.
  • 76. Johnson, P., and Rosenblatt, P. Grief following childhood loss of a parent. American Journal of Psychotherapy 35: 419-425, 1981. [PubMed: 7294256]
  • 77.
    Kaffman, M., and Elizur, E. Children's bereavement reactions following death of father: the early months of bereavement. International Journal of Therapy 1: 203-229, 1979.
    78.
    Kaffman, M., and Elizur, E. Bereavement responses of kibbutz and non-kibbutz children following the death of a father. Journal of Child Psychology and Psychiatry 24: 435-442, 1983. [PubMed: 6874787]
    79.
    Kane, B. Children's concepts of death. Journal of Genetic Psychology 134: 141-153, 1979.
    80.
    Kliman, G. Death in the family. In: Psychological Emergencies of Childhood (Kliman, G., editor. , ed.). New York: Grune and Stratton, 1968.
    81.
    Kliman, G. Facilitation of mourning during childhood. In: Perspectives on Be reavement (Gerber, I., editor; , Wiener, A., editor; , Kutscher, A., editor; , Battin, D., editor; , Arkin, A., editor; , and Goldberg, I., editor. , eds.). New York: Arno Press, 1979.
    82.
    Kliman, G. Childhood mourning: a taboo within a taboo. In: Perspectives on Bereavement (Gerber, I., editor; , Wiener, A., editor; , Kutscher, A., editor; , Battin, D., editor; , Arkin, A., editor; , and Goldberg, I., editor. , eds.). New York: Arno Press, 1979.
    83.
    Kliman, G. Death: some implications in child development and child analysis. Advances in Thanatology 4: 43-50, 1980.
    84.
    Koocher, G. Childhood, death, and cognitive development. Developmental Psychology 9: 369-375, 1973.
    85.
    Koocher, G. Why isn't the gerbil moving?: discussing death in the classroom. Children Today 4: 18-36, 1975.
    86.
    Koocher, G. Children's conceptions of death. In: New Directions for Child Development: Children's Conceptions of Health, Illness, and Bodily Functions , No. 14 (Bibare, R., editor; , and Walsh, M., editor. , eds.). San Francisco: Jossey-Bass, 1981.
    87.
    Krell, R., and Rabkin, L. The effects of sibling death on the surviving child. Family Process 18: 471-477, 1979. [PubMed: 527705]
    88.
    Krupnick, J., and Horowitz, M. Stress response syndromes: recurrent themes. Archives of General Psychiatry 38: 428-435, 1981. [PubMed: 7212973]
    89.
    LaGrand, L.E. Loss reactions of college students: a descriptive analysis. Death Education 5: 235-248, 1981.
    90.
    Leaverton, D., White, C., McCormick, C., Smith, P., and Sheikholislam, B. Parental loss antecedent to childhood diabetes mellitus. Journal of the American Academy of Psychiatry 19: 678-689, 1980. [PubMed: 7204798]
    91.
    . Levi, L., Fales, C., Stein, M., and Sharp, V. Separation and attempted suicide. Archives of General Psychiatry 15: 158-164, 1966.
    92.
    Leviton, D., and Forman, E. Death education for children and youth. Journal of Clinical Child Psychology 3: 8-10, 1974.
    93.
    Lifshitz, M. Long range effects of father's loss. British Journal of Medical Psychology 49: 189-197, 1976. [PubMed: 952778]
    94.
    Lloyd, C. Life events and depressive disorders reviewed: events of predisposing factors. Archives of General Psychiatry 37: 529-535, 1980. [PubMed: 7377909]
    95.
    Lonetto, R. Children's Conceptions of Death . New York: Springer, 1980.
    96.
    Markusen, E., and Fulton, R. Childhood bereavement and behavior disorders: a critical review. Omega 2: 107-117, 1971.
    97.
    Martinson, I., Moldow, D., and Henry, W. Home Care for the Child with Cancer : Final Report of Grant No. CA19490. Washington, D.C.: U.S. Department of Health and Human Services, National Cancer Institute, 1980.
    98.
    McConville, B., Boag, L., and Purohit, A. Mourning processes in children of varying ages. Canadian Psychiatric Association Journal 15: 253-255, 1970. [PubMed: 5427990]
    99.
    Menig-Peterson, C., and McCabe, A. Children talk about death. Omega 8: 305-317, 1978.
    100.
    Miller, I. Children's reactions to the death of a parent: a review of the psychoanalytic literature. Journal of the American Psychoanalytic Association 19: 697-719, 1971. [PubMed: 4946507]
    101.
    Morillo, E., and Gardner, L. Activation of latent Grave's disease in children. Clinical Pediatrics 19: 160-163, 1980. [PubMed: 6244127]
    102.
    Munro, A. Parental deprivation in depressive patients. British Journal of Psychiatry 112: 443-457, 1966.
    103.
    Munro, A., and Griffiths, A. Some psychiatric nonsequelae of childhood bereavement. British Journal of Psychiatry 115: 305-311, 1969. [PubMed: 5794124]
    104.
    Nagy, M. The child's theories concerning death. Journal of Genetic Psychology 73: 3-12, 1948. [PubMed: 18893204]
    105.
    Neubauer, P. The one-parent child and his Oedipal development. Psychoanalytic Study of the Child 15: 286-309, 1960. [PubMed: 13728484]
    106.
    Norton, A. Incidence of neurosis related to maternal age and birth order. British Journal of Social Medicine 6: 253-258, 1952. [PMC free article: PMC1012579] [PubMed: 12987634]
    107.
    Piaget, J. The Child's Conception of the World . London: Routledge; and Kegan Paul, 1951.
    108.
    Pitcher, E., and Prelinger, E. Children Tell Stories: An Analysis of Fantasy . New York: International Universities Press, 1963.
    109.
    Pitt, F., Meyer, J., Brooks, M., and Winokur, G. Adult psychiatric illness assessed for childhood parental loss and psychiatric illness in family members. American Journal of Psychiatry 121(12): 1-10, 1965. [PubMed: 14286065]
    110.
    Plank, E.N. Working with Children in Hospitals . Chicago: Year Book Medical Publishers, 1971.
    111.
    Plotkin, D. Children's anniversary reactions following the death of a family member. Canada's Mental Health , June: 13-15, 1983.
    112.
    Pynoos, R., and Eth, A. Witness to violence: the child interview. Presented at the Annual Meeting of the Academy of Child Psychiatry, Washington, D.C., October 1982.
    113.
    Pynoos, R., Gilmore, K., and Shapiro, T. The response of children to parental suicidal acts. Presented at the Annual Meeting of the Academy of Child Psychiatry, San Francisco, October 1983.
    114.
    Raphael, B. The young child and the death of a parent. In: The Place of Attachment in Human Behavior . (Parkes, C.M., editor; , and Stevenson-Hinde, J., editor. , eds.) New York: Basic Books, 1982.
    115.
    Raphael, B. The Anatomy of Bereavement . New York: Basic Books, 1983.
    116.
    Raphael, B., Field, J., and Kvelde, H. Childhood bereavement: a prospective study as a possible prelude to future preventive intervention. In: Preventive Psychiatry in an Age of Transition (Anthony, E.J., editor; , and Chiland, C., editor. , eds.). New York: Wiley, 1980.
    117.
    Raphael, B., Singh, B., and Adler, R. Childhood loss and depression. Paper presented at the meeting of the Section of Child Psychiatry, Royal Australian and New Zealand College of Psychiatrists, Sydney, Australia, April 1980.
    118.
    Reed, E. Helping Children with the Mystery of Death . New York: Abingdon Press, 1972.
    119.
    Remus-Araico, J. Some aspects of early-orphaned adults analysis. Psychoanalytic Quarterly 34: 316-318, 1965.
    120.
    Rochlin, G. The loss complex. Journal of the American Psychoanalytic Association 7: 299-316, 1959. [PubMed: 13641076]
    121.
    Rochlin, G. The dread of abandonment: a contribution to the etiology of the loss complex and to depression. Psychoanalytic Study of the Child 16: 451-470, 1961.
    122.
    Rochlin, G. Griefs and Discontents . Boston: Little, Brown, 1965.
    123.
    Rosenheim, E., and Ichilov, Y. Short-term preventive therapy with children of fatally-ill parents. Israeli Annals of Psychiatry and Related Disciplines 17: 67-73, 1979. [PubMed: 287661]
    124.
    Rosenzweig, S., and Bray, D. Sibling deaths in the anamneses of schizophrenic patients. Archives of Neurology and Psychiatry 9: 71-74, 1943.
    125.
    Roy, A. Vulnerability factors and depression in women. Psychiatry 133: 106-110, 1978. [PubMed: 678732]
    126.
    Rutter, M. Children of Sick Parents . London: Oxford University Press, 1966.
    127.
    Schmale, A., and Iker, H. Hopelessness as a predictor of cervical carcinoma. Social Science and Medicine 5: 95-100, 1971. [PubMed: 4397331]
    128.
    Seligman, R., Gleser, G., and Rauh, J. The effect of earlier parental loss in adolescence. Archives of General Psychiatry 31: 475-479, 1974. [PubMed: 4419535]
    129.
    Sethi, B. Relationship of separation to depression. Archives of General Psychiatry 10: 486-496, 1964. [PubMed: 14120578]
    130.
    Shambaugh, B. A study of loss reactions in a 7 year old. Psychoanalytic Study of the Child 16: 510-522, 1961.
    131.
    Shepherd, D., and Barraclough, B. The aftermath of parental suicide for children. British Journal of Psychiatry 129: 267-276, 1976. [PubMed: 963364]
    132.
    Spinetta, J.J. The dying child's awareness of death: a review. Psychological Bulletin 81: 256-260, 1974. [PubMed: 4594964]
    133.
    Spitz, R. The First Year of Life: A Psychoanalytic Study of Normal and Deviant Development of Object Relations. New York: International Universities Press, 1965.
    134.
    Stone, M. Depression in borderline adolescents. American Journal of Psychotherapy 35: 383-399, 1981. [PubMed: 7294253]
    135.
    Tallmer, M., Formanek, R., and Tallmer, J. Factors influencing children's concepts of death. Journal of Clinical Child Psychology . Summer: 17-19, 1974.
    136.
    Tennant, C., Bebbington, P., and Hurry, J. Parental death in childhood and risk of adult depressive disorders: a review. Psychological Medicine 10: 289-299, 1980. [PubMed: 7384330]
    137.
    Van Eerdewegh, M., Bieri, M. Parilla, R., and Clayton, P. The bereaved child. British Journal of Psychiatry 140: 23-29, 1982. [PubMed: 7059737]
    138.
    Vaughan, V.C. Critical life events: sibling births, separations, and deaths in the family. In: Developmental-Behavioral Pediatrics (Levine, M., editor; , Carey, W., editor; , Crocker, A., editor; , and Gross, R., editor. , eds.). Philadelphia: W.B. Saunders, 1983.
    139.
    Wahl, C. The fear of death. In: The Meaning of Death (Feifel, H., editor. , ed.). New York: McGraw Hill, 1959.
    140.
    Watt, A. Helping children to mourn. Parts I and II. Medical Insight 15: 29-62, 1971.
    141.
    Wilson, I., Alltop, L., and Buffaloe, W. Parental bereavement in childhood: MMPI profiles in a depressed population. British Journal of Psychiatry 112: 761-764, 1967. [PubMed: 4383402]
    142.
    Wolfenstein, M. How is mourning possible? Psychoanalytic Study of the Child 21: 93-123, 1966. [PubMed: 5965407]
    143.
    Wolfenstein, M. Loss, rage, and repetition. Psychoanalytic Study of the Child 24: 432-460, 1969. [PubMed: 5353373]

    Footnotes

    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 assistance were provided by committee members Gerald Koocher, Ph.D., and Theodore Shapiro, M.D., and by Fredric Solomon, M.D.

    Copyright © 1984 by the National Academy of Sciences.
    Bookshelf ID: NBK217849

    Views

    • PubReader
    • Print View
    • Cite this Page
    • PDF version of this title (2.5M)

    Related information

    • PMC
      PubMed Central citations
    • PubMed
      Links to PubMed

    Recent Activity

    Your browsing activity is empty.

    Activity recording is turned off.

    Turn recording back on

    See more...