The effects of bereavement in childhood
Dora Black
David Trickey
Introduction
Bereavement is not an illness in itself, although it may cause illness or predispose to one. The reaction to the loss of a loved one may lead to temporary or long-term psychological distress and/or loss of function, and may occasion consultation with the general practitioner and referral to mental health professionals.
During the first two years of life, through instinctive behaviours which are modified by experience, infants and their main carers develop an attachment. This bond between a child and his caretaker(s) ensures the child’s survival, enables his or her optimum physical, intellectual, and emotional development, and in due course ensures the survival of the species. The nature of the attachment between infant and carer(s) influences the way in which children come to view their social world; the pattern of attachment developed in the first two years of life often remains stable and is associated with the way in which children relate to other people later in their life. Attachment behaviour has been observed across different species and has obvious benefits for survival. However, part and parcel of attachment for the child is distress at separation. Infants who develop a secure attachment can gradually tolerate longer periods of separation from their carer and any distress is rapidly assuaged when they are re-united with their carer. When considered within the context of attachment theory, it is inevitable that permanent separation (e.g. through bereavement) will cause distress for the bereaved. Parkes reviews the body of attachment research and offers a comprehensive description of attachment with particular reference to its role in understanding the impact of loss.(1)
The DSM-IV-TR has a classification for ‘Bereavement’ (V62.82) differentiating it from ‘Major depressive disorder’ (296.2) which, unless the symptoms are severe, is generally not diagnosed until 2 months after the loss. ICD-10 has no separate classification for bereavement and suggests the use of ‘Adjustment disorders’ (F43.2) for temporary reactions to life-events, and ‘Death of a family member’ (Z63.4) for normal bereavement reactions not exceeding 6 months in duration.
In industrialized countries between 1.5 and 4 per cent of children are orphaned of at least one parent in childhood. Premature deaths in the parenting years may be due to illness, accident, war, civil conflict, natural and man-made disasters and the incidence of these are all higher in developing countries. It is estimated by UNICEF that, in some developing countries, 21 per cent of children are orphaned of at least one parent; with HIV AIDS responsible for up to three-quarters of the deaths.(2)
Reactions to the death of a parent
Research studies
It is generally accepted that loss of a parent in childhood is associated with harmful psychological consequences, however it is difficult to tease out the independent effects of adverse circumstances before the death, the loss itself and the subsequent disruption to the child’s life, including the possibility of compromized parenting post-bereavement(3,4). Most published research about bereaved children describes small-scale uncontrolled studies carried out on children and adolescents referred to mental health facilities. Dowdney comprehensively reviews the research examining the psychological impact of being bereaved of a parent in childhood. She concludes that despite methodological weaknesses, certain findings consistently emerge: ‘Children do experience grief, sadness, and despair following parental death. Mild depression is frequent, and can persist for at least a year after parental death’. Bereaved children commonly exhibit a range of psychological symptoms that may not constitute a specific disorder, but the severity of which is likely to warrant referral to a specialist service for one in five bereaved children.(5)
Long-term effects of bereavement
There continues to be debate about a possible link between being bereaved of a parent as a child, and mental health as an adult. The debate is complicated by methodological weaknesses in studies, inconsistent results and difficulty in isolating the impact of experiences which may precede or follow the loss. Any long term consequences of parental bereavement can be mitigated by the subsequent provision of adequate parenting(6, 7). Furthermore, studies in behavioural genetics are increasing the understanding of how genetic endowment interacts with environmental hazards to lead to the presence or absence of mental health problems.(8)
Cultural and religious issues
Reactions to loss are biologically based and are therefore likely to transcend cultural differences, although culture may modify their expression.(3) Religious beliefs about what happens after death can be confusing to young children at the stage of concrete thinking and need to be presented taking account of their developmental stage. A helpful text(9) gives guidance on religious and cultural differences in the conceptualization of death.
Developmental issues
Young children react to the absence of a parent by developing an anxiety or depressive reaction, often expressed somatically (regression
in acquired control, anorexia, insomnia), but young children cannot distinguish temporary from permanent loss(3,10). Research consistently demonstrates that children ordinarily do not develop a full understanding of the concepts of death before the age of 7 years, although younger children of 4 years and above can understand it with appropriate help.(11)
in acquired control, anorexia, insomnia), but young children cannot distinguish temporary from permanent loss(3,10). Research consistently demonstrates that children ordinarily do not develop a full understanding of the concepts of death before the age of 7 years, although younger children of 4 years and above can understand it with appropriate help.(11)
Pre-pubertal schoolchildren can be helped more easily to comprehend the reality of death, especially if they are given an opportunity to see for themselves the cessation of function. In cultures where viewing the body is the norm, there may be fewer misconceptions about death among children, but this should not be undertaken where the body is mutilated.(12) Although difficult to substantiate scientifically, clinical literature suggests that attending the funeral helps the grieving process.(5)
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