Journal of Child and Adolescent Psychiatric Nursing: Decreasing the Risk of Complicated Bereavement and Future Psychiatric Disorders in Children

FindArticles > Journal of Child and Adolescent Psychiatric Nursing > Apr-Jun 2005 > Article > Print friendly

Decreasing the Risk of Complicated Bereavement and Future Psychiatric Disorders in Children

Kirwin, Kathleen M

Decreasing the risk of complicated bereavement and future psychiatric disorders in children. This literature will determine what major factors influence a child's response to death and to understand how children react to the death of a parent at different developmental stages. It will evaluate the following: a) What are children's emotional responses to the death of a parent? b) How can a surviving parent help the grieving child complete the tasks of grieving? c) What skills are important for a parent to learn in order to help the grieving child through the tasks of grieving and d) How can mental health providers help the grieving family and the grieving child? Relevant literature from child psychiatry, child psychology, and nursing. The death of a parent is a major stressful event for children and their families. This traumatic event can bring serious psychological and social distress to bereaved children and their families. Children who are not supported in the early phases of grieving can develop serious emotional and behavioral problems that can lead to the development of some major psychiatric disorders. Providing early prevention support programs for surviving parents and bereaved children can help both the parents and the children adapt to their losses. These structured programs can decrease the risk of complicated grief in bereaved families. More research studies are needed to validate the effectiveness of these early prevention program interventions. Children and adolescent grief, attachment, and parental loss

This paper investigates how the death of a parent is a risk factor in developing future psychiatric disorders in children and adults. This paper also covers the current methods of assessment for children at high risk for developing complicated grief, as well as reviews the current successful interventions from published journal articles and published books on loss and the grief process.

Demographics

According to the 1989 United States Bureau of Census, approximately 1.5 million children live in a single-parent home because the other parent is dead (as cited in Silverman & Worden, 1992). Steen (1998) accurately predicted that during 1999 in the United States, it was possible that one or two of every 10 American adults will suffer a death of a family member. This statistic leads to the fact that there are more than 15 million widowed adults in this country. The number of American children under the age of 15, who will suffer from the loss of a parent or both parents, is one out of every 20 (Steen, 1998).

The death of a parent is considered one of the most significant and stressful events for children and their families. When a parent dies, it affects each member of the family and the family as a whole. How the surviving parent copes with the loss of their partner affects how their children work through the tasks of grieving. Bereaved parents may have difficulty dealing with their feelings and grief issues, which will impair their ability to parent their children. These children may then have to deal with major psychiatric problems and social dysfunction in their childhood and possibly throughout their adult lives. The death of a parent affects a child's self-concept, health, social, and economic circumstances (Steen, 1998).

Currently, the need for mental health providers to understand the grief process has increased as a result of the terrorist events on September 11, 2001. The people of the United States of America and many other countries suffered a great loss of lives in New York, Washington D. C., and Pennsylvania. Thousands of civilians, military personnel, and rescue workers were killed through acts of terrorism. Many of them left behind children who are now grieving the loss of their mother, father or both parents. The number of children who lost a parent or parents, varies between 10,000 to 15,000. It has been established that 4,000 qualify as orphans under the Twin Towers Orphan Fund. There are 1,500 children left by the 700 missing Cantor Fitzgerald employees alone (The Avalon Project at Yale Law School, September 11, 2001: Attack on America, Congressional Record House Children Who Lost A Parent or Guardian on September 11, 2001, Must be Provided for; October 30, 2001). We all need to understand that all children who have lost a parent to death suffer in many ways and may need mental health services. September 11 has highlighted for us that it is important that mental health professionals understand how children grieve.

Psychiatric Sequela in Adulthood of Unresolved Grief during Childhood

Studies confirm that adults who were unable to move through the tasks of grieving as children are at significant risk for developing depression and anxiety (Saler & Skoinick, 1992; Mireault & Bond, 1992). Saler & Skoinick (1992) looked at adults who, in their childhood, experienced the death of a parent. In this study, they were looking at the following effects: the quality of parenting by the surviving parent after the other parent's death and the type of home environment that was present after the parent's death.

Standardized measures were used to directly examine the subjects' perceptions of their relationship with the surviving parent and the nature of the family environment. The participants were selected from a group that responded to a public notice. The people who responded were sent a brief description of the study, a consent form and five questionnaires. Out of 109 questionnaire packets, 90 adults participated in the study.

Criteria for participation included one parent die before they were 18 years old, they had to be between the ages of 20 and 50, and they had to have a minimum of two years since the death of any participants' surviving parent. The mean age of the subjects was 32.2 years old; 42% (38) were male and 58% (52) were female. The majority of the sample (61%) was single and 21% were married, 11% were divorced or separated, and 2% were widowed. The majority of the sample was White (91%), the rest identified themselves as Asian, Black, Hispanic, or other. The sample consisted of the following: 41% were college graduates, another 23% had master's degrees, and 16% had doctoral degrees, 11% had completed some college, and the remaining 9% were high school graduates.

In the sample, 87% of the subjects had parents who were married at the time of the death of one parent. Also, 70% of the subjects deceased parent was the father, for the remaining 30%, it was the mother who was deceased. The subjects' mean age at the time of the parent's death was 10.58. Cancer was identified as the most frequent cause of death (28%), closely followed by heart attack (26%), and accidents (14%). Two percent of the subjects reported that the parent committed suicide, while the remaining 30% reported other medical illnesses as the cause of death (Saler & Skoinick, 1992). For the measurement tools, results and the limitations of this study see Table 1.

Mireault arid Bond (1992) examined the relationship between perceived vulnerability to loss and depression and anxiety in young adults who lost a parent before the age of 18. This study recruited 17-25-year-old undergraduate students at a moderately-sized New England state university. The experimental group included those subjects who had lost a parent through death. The sample was made up by 127 bereaved and 166 nonbereaved subjects. Sixty-four percent of the final sample was female. The mean age was 19.8 years old and the mean year in college was sophomore, with an average GPA of 2 (Mireault & Bond, 1992). The measuring tools used by Mireault & Bond (1992) were:

* demographic questionnaire;

* the Brief Symptom Inventory (BSI) - assessed nine symptom dimensions, including anxiety and depression;

* Perceived Vulnerability - a scale designed for the research. The modified scale allows the evaluator to indicate on a seven-point scale the frequency with which the subject thinks about, rather then worries about, future negative events;

* the Multidimensional Scale of Perceived Social Support (MSPSS) - was used to assess social support - friends, family and significant others. The regression analysis leans towards supporting that perceived vulnerability acts as a cognitive mediator in the development of anxiety and depression. As hypothesized, the bereaved subjects scored higher than the control group on perceived vulnerability. However, contrary to the hypothesis, when ANOVAS were completed to determine the differences in anxiety, depression, and perceived vulnerability between bereaved subjects and the nonbereaved control group, there were no differences in anxiety and depression. The authors suggest that further research needs to be carried out on resiliency of children who lose a parent through death (Mireault & Bond, 1992).

Reasons for the Lack of Psychiatric Services for Bereaved Children

According to Black (1998), Dowdney, Wilson, Maughan, Allerton, Schofield & Skuse (1999), and Weller, Weller, Fristad, & Bowes (1991), bereaved children have higher levels of emotional disturbance and symptoms than nonbereaved children for up to 2 years after the death of a parent and up to 40% of bereaved children show disturbance 1 year after bereavement. Weller et al. (1991) found in their study, that 37% of the 38 bereaved children had a major depressive disorder 1 year after bereavement.

In the Dowdney et al. (1999) prospective case-control study, parentally bereaved children and surviving parents showed higher then expected levels of psychiatric difficulties. The psychiatric services offered was related to the age of the child and the manner in which the deceased parent died. Children under 5 years old were less likely to be offered services than older children even if their parents wanted the services. The children who lost the parent through suicide or from a terminal illness had significantly higher change of being offered services. The children least likely to receive psychiatric services were those who were not involved with any services before the parental death.

Dowdney et al. (1999) found that despite the risk for bereaved children of developing major psychiatric disorders, mental health services are not routinely offered. Some of the reasons they found for the lack of services to this population of children are as follows: Mental health professionals disagree about whether bereaved children require mental health services. There is a lack of information about the grieving process of children. Also, there is a lack of specifics for identifying children who might be at high risk for the development of complicated grief. Surviving parents may be preoccupied with the everyday difficulties of caring for the needs of the family and may not be aware of the children's need to express their feelings about their loss. If the surviving parent is the father, he may be less aware of his children's needs to work through the grief tasks and emotional pain. Also, the surviving parent may be dealing with their own mental health issues and complicated grief.

Other reasons for the lack of services are the myths about grieving children. There has been a long-standing debate about children's capacity to grieve. Children's grief has not received much attention from clinicians and researchers. This adds to the lack of consensus about whether children actually mourn (Dowdney et al., 1999). see the myths of children's grief in Table 2.

Early theorists such as Wolfenstein in 1966, (as cited in, Geis et al., 1998, p. 75) felt that grieving does not occur until adolescence, as a result of the younger child's psychological structure and the fact that object relations are not fully developed. Bowlby in 1960, (as cited in Geis et al., 1998, p. 75) on the other extreme described very young children's reactions to loss of a loved one. The reactions included protest, despair and detachment. Furman in 1974 (as cited in Geis et al., 1998, p. 75), believed that children are able to mourn once object constancy of the loved one has been maintained. This task is usually achieved between 6 months and 1 year of age.

Conceptual Framework

The trauma of loss has a direct effect on children who are trying to cope with the death of a parent. The theories regarding the trauma of loss are becoming more developed (Black, 1998; Bowlby, 1980; Geis et al., 1998; Worden, 1991). Researchers and clinicians have utilized several theoretical concepts to provide meaning to the grief process.

In 1961, Bowlby developed phases of grief from his attachment theory. His theory helps others understand that there are reasons for the ways humans react to grief. During the development of healthy humans, instinctive attachments are developed, first between the child and parent, then between adults. The goals of attachment behaviors are to maintain a homeostatic relationship with loved ones (Rando, 1984, p. 21).

Black (1998) relates that infants come into the world with complex behavioral systems already in place. One system involves the infant engagement of the caretaker in a mutual bonding by using instinctively the behaviors of smiling, cooing, and crying. This system is an important source of security throughout a person's life. Another system involves the development of mutual bonding behavior that ensures that the child does not stray from a caretaker. Later in toddlerhood, this typically leads the child to go exploring only to return and check on the caretaker's presence.

When faced with the separation and loss of an attachment figure, infants and toddlers will protest loudly. If the attachment figure or caregiver does not return as a result of death, illness, or divorce, then the child is likely to show a great amount of despair and detachment. The young child may display grief reaction by developing feeding problems, bed-wetting, constipation, and sleeping problems (Black, 1998).

Worden (1991) states that Bowlby's attachment theory gives us a way of conceptualizing the tendency in human beings to make strong, affectionate bonds with others, and to understand those bonds. It is also a way for us to understand the strong emotional reaction that occurs when those bonds are threatened or broken. Worden (1991) utilizes the ethologic theory to further state that animals, as well as humans utilize attachment as a way to survive. Geis et al. (1998) point out that if the attachment to a loved one is lost through death, then grief follows in response to the separation. Separation anxiety can be observed in both humans and animals. Worden (1991) cited a study carried out by Lorenz where he describes grief-like and separation anxiety-like behavior in the separation of a greylag goose from his mate.

The behavioral theory (Stroebe & Stroebe, 1987 as cited in Geis et al., 1998, p. 74) is based on the idea that behaviors elicit reinforcement from others. When someone we love dies, certain behaviors no longer produce the same rewards. In addition, there is an increase in the number of aversive events associated with the loss. This produces sadness and other unpleasant feelings. This change in reinforcement and the increase in aversive events produce the symptoms of grief.

According to Geis et al. (1998, p. 74), "the cognitive approach uses the attribution theory and the learned helplessness model to understand grief." The person experiencing grief feels unable to change and is helpless about the death of a loved one. This will result in the survivors' sense of decreased control. The survivors may assume a degree of responsibility for the death of a loved one and then will wonder if anything could have been done to prevent it.

Definition of Terms

The terms grief, mourning and bereavement are used continuously when referring to the loss of a loved one. In the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV, 1994, pp. 684-685):

Bereavement is a category that can be used when the focus of attention for the clinician is on the survivor's reaction to the death of a loved one. As part of the reaction to the loss, the individual may have symptoms of a major depressive episode, but the depressed mood is considered normal. The duration and expression of normal bereavement may vary with different cultures. The diagnosis of major depressive disorder is not given unless symptoms persist, and are still present after 2 months from the date of the loss.

A clinician can differentiate if a client discloses symptoms not characteristic of a normal grief reaction, which include the following:

* guilt about things, other than the circumstances of the death;

* suicidal thoughts other than the survivor feeling he/she would be better off dead or should have died;

* severely overly preoccupied with worthlessness;

* severe psychomotor retardation;

* prolonged and severe functional impairment; and

* hallucinations other than transient experiences of thinking he/she hears the voice or sees the image of the deceased loved one.

According to Steen (1998), bereavement is the internal process of having lost a significant other; grief is the personal response to the loss; mourning is the external expression or public expression of that loss. Bereavement can be an intensely demanding, multidimensional adaptive process. As such, it is both an opportunity for significant personal growth and an opportunity for the development of disease, be it mental or physical consequences (Steen, 1998). In Sheldon's clinical review (1998), bereavement is described as a human experience that can be potentially dangerous to one's health. It is associated with high mortality, and up to a third of bereaved people develop depressive illness. In a study conducted by Geis et al. (1998), grief is defined as being the emotional response to an automatic process that follows a loss. Bereavement is the destitute feelings that accompany separation and detachment.

In contrast to the concept of detachment, Silverman, Nickman, & Worden (1992), had different observations. Their study was based on interviews with children who had lost a parent, in an attempt to understand the bereavement process. This was a nonexperimental, longitudinal study of 70 families with 125 children. In this study, there was an equal number of girls and boys and the average age was 11.6 years. The data for the study was taken from two semi-structured research interviews, given at 4 months after death and again 1 year later. The authors of the study proposed that the children did not detach from the deceased loved one; rather they maintained a presence and connection with the deceased.

The strategies of connection identified by Silverman et al. (1992) are as follows: 74% of the children believed the deceased was located in heaven. Eighty-one percent of the children felt that their deceased parents were watching them and of those who felt watched (57%) were scared because they were afraid that their dead parent might not approve of what they were doing. Another way the children experienced the deceased was through dreams, as 45% of the children reported dreams about their parents. Some of the children took the initiative to keep a connection by visiting the cemetery. Fifty-seven percent of the children spoke to the deceased parent and 43% felt they received answers. Ninety percent of the children had daytime memories. Out of the 125 children, 77% had transitional objects, which is something personal that belonged to the dead parents. As the first year of mourning proceeded, some of these transitional objects became less powerful and more like precious keepsakes.

Children's Concept of Death

Infancy

Joy Johnson (1999), a bereavement specialist, acknowledges that infants respond to the grief of survivors around them. The infant responds to the changes in the schedule, the tension he or she feels in his or her loved ones, and to the disruption in the home. Geis et al. (1998), states that children between 6 months and 1 year can maintain object constancy (which is an internal representation) of their caregiver even when this person is absent. Which leads to the conclusion those young children can experience an emotional reaction following the death of a caregiver.

Toddlers and Preschoolers

According to Johnson (1999), toddlers between the ages of 2-5 have little sense of permanence; they may ask when the deceased is going to come back. The toddler may regress to a younger stage of development when the family was in a safer time, before the death of the family member.

The family may find that the toddler becomes clinging, whiny, starts bedwetting, and may have more physical illnesses. The toddler at this age will alternate between grieving behavior and playing behavior. A toddler's lack of a sense of permanence and magical thinking may play a part in how he or she perceives the loss of a loved one (Johnson, 1999).

According to Geis et al. (1998), during the preschool years, children can display regressed behaviors during mourning. These children have short attention spans and cannot deal with intense emotions for prolonged periods of time. The adults in their lives may conclude that these children are not dealing with sadness or grief. Preschool age children use play activities to cope with strong feelings, which may lead adult family members to believe that they are not grieving.

School-Age Children

In Black (1998), Geis et al. (1998), Silverman & Worden (1992) and Steen (1998), there has been a longstanding discussion about whether school-age children have the capacity to grieve. Black (1998) states that at age 5, many children can understand the difference between a temporary separation and death. They may know that death is irreversible. In children from 5-11 years old, there is an increased understanding that there are bodily changes that occur with death.

According to Geis et al. (1998) bereaved school age children are also vulnerable to regressive behavior under stress and may begin the use of magical thinking patterns which are characteristic of preschool children. Peers tease some school age children because their loss makes them different. Some school-age children can develop school problems resulting from a decrease in the ability to concentrate because of thoughts of the deceased. Other children may develop other worries, somatic complaints, accident proneness, and suicidal ideation.

Johnson (1999) stated that 6-9-year-olds begin to understand that death is final. These youngsters may not want to acknowledge this. They may have scary ideas about death. They may be fearful because of magical thinking about death. They may believe that death is contagious, or death is a person like a ghost or the grim reaper.

Johnson (1999) also states that with 10-12-year-olds, friends are very important and they may think that grieving will make them different from their peers. The older school age children want to be independent but cannot be on their own. They may fear being abandoned, fear the death of others and of their own. They may worry more about the surviving family members. They may seem more withdrawn and distant rather than want to be close. They have a strong sense of what is right and wrong. Death may be perceived as a punishment.

Teenagers

According to Johnson (1999) and Wolfelt (1996), teenagers developmentally are going through a major transitional period. They are leaving the security of their childhood. They may be missing the childhood experiences such as cuddling on laps, or being read to by a loved one or getting toys for presents. They begin to separate from their families to establish their own identities and individuate. They may feel guilty if there is a death in the family because they are separating from their family of origin that may have been full of tension and fights. The adolescents' changing bodies make them appear more like adults, and adults may assume that adolescent age children, with their more adult-like physical features, are emotionally mature enough to handle their feelings of grief.

There can be differences in the way male and female adolescents respond to the death of a loved one. Boys may become more aggressive and refuse to admit to their feelings. They may also physically act out or use drugs or alcohol. Girls may need their friends for comfort and support (Johnson, 1999; Wolfelt, 1996).

Wolfelt (1996) identified a behavior that parents and clinicians (if involved) need to watch for as follows: suicidal thoughts or actions, long-standing depression, isolation from friends or family, failing in school or overachieving, major changes in their personality or attitude, serious eating problems, drug or alcohol abuse or both, fighting or criminal behaviors, and inappropriate sexual behaviors.

Silverman & Worden (1992) and Geis et al. (1998) state that children's affective response to grief includes crying, insomnia, learning difficulties, and early health problems that may be resulting from internalization of their feelings. In fact, Silverman & Worden's (1992) study of 125 bereaved children found that 62% of the children were no longer crying at frequent intervals after 4 months; while 8% of the younger children reported daily crying. Seventy percent of the children slept well; the remaining one-third had sleeping problems such as difficulty falling asleep or early morning awakening. Seventy-four percent of the children experienced headaches, 19% had difficulty concentrating in school, and 18% had uneasiness at the absence of their dead parent from the dinner table.

The researchers went on to form a principal factor that they identified as "emotional distress". Children with the highest distress scores were doing poorly in school, experienced more problems with peers for having a dead parent, were more preoccupied with thoughts of their dead parent, and had more health problems.

Geis et al. (1998) found that the loss of a parent affects children in many ways. There are changes in both the family life and in the daily routine. Other adults may provide for basic survival needs. Such a major loss leaves the children with an emotional void and creates a sense of fear about a once-secure world. The children's immediate reactions to the death of a parent may appear brief, when in fact the parent's death continues to influence the child's life in each new developmental stage. see Table 3 for a list of how to help children cope with bereavement at each developmental stage.

The Psychological Tasks of Grieving

There have been numerous contributors to the evolutionary process of grief work. Theresa Rando (1984) states that Lindermann (1944) offered three tasks for working through the grief process. These tasks are as follows:

1. Emancipation from the bondage of the deceased. According to psychoanalytic terms, when a person loves someone, he or she becomes emotionally bonded to that person. This is called cathexis. Within this emotional bond, the individual invests his or her psychic and emotional energies in the loved one. When this loved one dies, the one left behind has to withdraw his or her energies as a result of the death. The person who lives develops new, altered attachments in the form of memories.

2. Readjustment to the environment in which the deceased is missing. The person who is grieving develops a new view of the world without the loved one. The person will need to redefine his or her roles and skills to incorporate the functions the deceased performed. There are many distressing feelings that happen with these adjustments. The loss of a loved one affects the individual in many ways: emotionally, somatically, socially, and financially.

3. Formation of new relationships. The emotional energy that is displaced from the relationship with the deceased is reinvested to someone new or something else (Rando, 1984, pp. 18-19).

Processing grief is difficult work and requires strenuous effort on the part of the bereaved individual. In our society, we have unrealistic expectations and often have inappropriate responses to the grievers' normal responses to their loss. This will often make the grief work even more difficult than it needs to be. The work involves not only grieving the loss of the loved one but the losses of all that made their relationship, with the hopes, dreams, fantasies, and unfinished expectations that the person had for the deceased (Rando, 1984). see Table 4 for the next theorists that added to stages or phases of grief.

In Baker, Sedney, & Gross (1992), Heiney, Dunaway, & Webster (1995), Steen (1998), and Worden (1996), there are normal tasks or phases of grieving. In Baker et al. (1992), the grief process is seen as a series of tasks that must be accomplished over time (see Table 5). The concepts of the tasks are based on Bowlby's stages. The early tasks are during the initial stage of numbness, the middle phase tasks take place during the time of yearning and despair, and the late tasks are those that must be dealt with during the final period of reorganization.

The clinical implication of the initial stage is that children need extra support from their families. During this stage, psychoeducation is important for the adults in the families. The psychoeducational work with the parental figures should help develop an understanding of children's developmentally-based needs and abilities (Baker et al, 1992).

In the middle phase, the clinical focus is on the emotional pain of grief. For therapists, the middle phase is the time to closely monitor the issues that stem from the child's ambivalent feelings towards the individual before the death, and the issues that arise after the death of a loved one. The therapist needs to be aware of the child's feelings. The child may feel angry with the dead parent for abandoning him or her, or might have feelings of guilt because the child thinks he or she may have driven the person away. The therapist needs to be aware that the child could have difficulty verbalizing these feelings. (Baker et al., 1992).

In Baker et al.'s (1992) late phase of grieving, the focus is on the child's reorganization of identity and significant relationships in his or her life. In psychotherapy, the child can explore his or her new personal identity and work through any conflicts that may arise with the child developing new relationships. In family therapy, the parent can be helped to understand the meaning of any reoccurrence of grief-related emotions after what seems to be a long period of time. The parent can work on any unresolved grief as well, in an attempt to help promote the child and the parent through the tasks of grieving (Baker et al., 1992).

Worden (1996) disagrees with Baker et al. (1992) on the number of tasks of mourning. He identifies four tasks of mourning that he modified to match the age and developmental level of the child. The comparison of Baker et al.'s (1992) and Worden's (1996) tasks of grieving can be seen in Table 5. As with other theories of the tasks of grieving, these tasks of grieving occur on a continuum. The individual moves in and out of these tasks of grieving on their own time frame. The psychosocial factors that can influence an individual's grief reaction can be seen in Table 6.

Alan Wolfelt is a noted grief counselor who has written numerous books on the grieving and mourning process of children and adults. He stresses that grief work is a journey because the death of a loved one changes our lives forever. He also states that children heal over time as they proceed through their grief journey with the guidance of companions, which can be a counselor, a parent or an adult caregiver.

Psychiatrie Disturbance in Parentally-Bereaved Children and Their Surviving Parents

According to Black (1998) and Geis et al. (1998), there are a number of factors inherent to the child, the family's, circumstances of the death and how the child is told about the death that will affect the child's reactions to the death of a parent (Table 6).

In Geis et al. (1998), preschool children have a higher incidence of separation anxiety and other fears after the death of the father. Children of depressed surviving parents do not receive the extra support they need from their parents. According to Geis et al. (1998), Kranzler and colleagues found that in their work with the bereaved, depressed surviving parents were the most powerful predictor of disturbance in preschool children who lost a parent. Fristad and colleagues (as cited in Geis et al., 1998) found that older children, particularly boys, demonstrated more school difficulties and the death of a father lowered their self-esteem. Older children appear more vulnerable to feelings of guilt than younger children. Depression appears to be more common if the mother is the surviving parent.

Weller, et al. (1991) conducted a nonexperimental, between-subjects, and cross-sectional, structured design study, with a subject size of 38 bereaved children. The comparison group consisted of 38 depressed children from a child psychiatric inpatient unit. The children from the comparison group were matched to the bereaved subject for age, sex and socioeconomic status.

The bereaved children and parents were interviewed 312 weeks after the death of the parent. Structured interviews and rating scales were used, which included the Diagnostic Interview for Children and Adolescents. These structured interviews established the presence or absence of psychiatric diagnoses for the child on the basis of DSM-III criteria. The parents of the children completed the Psychiatric Interview genogram. The results of the study were rescored to fit the DSM-III-R criteria for a major depressive episode. The nine symptoms are based on the DSM-III-R criteria: dysphoria, loss of interest, appetite disturbance, psychomotor agitation or retardation, fatigue, excessive guilt, and worthlessness, trouble thinking, and morbid or suicidal ideation (Weller et al., 1991).

The results of the study indicated that symptom endorsement was least frequent for the bereaved children when only the parent's report was used. When the child's report was used, endorsements were more frequent. Symptom endorsement was most frequent when the child and parent reports were combined. When both reports were used, more than 37% of the bereaved children met the DSM-III-R criteria for a major depressive episode (Weller et al., 1991).

This study revealed that bereaved children experienced numerous depressive symptoms but had fewer symptoms than inpatient children with major depression reported. The symptoms seen more in bereaved than depressed children were guilt and worthlessness. This study also indicates that some bereaved children have symptoms of depression. There is a need for more research to further investigate the prevalence of depression and other psychiatric disorders in bereaved children (Weller et al, 1991).

In Weller et al. (1991), bereaved children may have suicidal ideation, but attempts are rare. The suicidal ideation is related to a desire to be with the deceased for bereaved children, opposed to a devaluation of life for depressed children.

Dowdney et al. (1999) conducted a prospective case control study to identify whether psychiatric disturbance in parentally bereaved children and surviving parents is related to the family receiving mental health services. This study had 45 bereaved families participate, the measurement used on the parents was a semistructured interview and for the children, child behavioral checklists completed by the parents and for school-aged children, their teachers' completed report form. These child mental health assessment tools measured a broad range of symptoms, which included:

a) internalizing scale: withdrawn, anxious, and depressed behaviors; and

b) externalizing scale: disruptive, aggressive, or delinquent behaviors.

The results indicated that 29 parents (63%) scored high enough on the rating scale to have probable psychiatric disorders. The parent report of the children's scores indicated a wide range of emotional and behavioral problems. The median scores were above the population mean for 25 (63%) children on the internalizing scale, (which included the following behaviors: withdrawn, somatic, anxious or depressed), 23 (58%) children on the externalizing scale (which included delinquency and aggression). This study showed that bereaved boys had significantly higher externalizing and total problem scores than bereaved girls (Dowdney et al., 1999).

This study had several limitations in that it had a small sample size, and it may not represent the larger bereaved children population. It does indicate that there are significant emotional and behavioral problems in their sample population that could use a mental health intervention (Dowdney et al, 1999).

Complicated Bereavement:

Worden (1991) and Rando (1984) described why people have difficulty completing the grieving process. Worden (1991) listed several factors that interfere with the grief process. These factors are:

* Relational: what type of relationship did the person have with the deceased?

* Circumstantial: what was the circumstance that surrounded the death? Such as a person who is missing and is there evidence that the person is dead?

* Historical: did the bereaved person have complicated grief reaction in the past?

* personality: the bereaved person's character and how he or she copes with emotional distress.

* Social: if the nature of the death has any social stigma, such as suicide. If the bereaved person and those around him or her act as if the loss did not happen. If the bereaved person does not have a support system (Worden, 1991).

According to Rando (1984), there are seven forms of unresolved grief. These forms can overlap, and each has components of denial or regression. These seven forms of unresolved grief are:

* Absence of grief: the feelings of grief and mourning are absent.

* Inhibited grief: there is an inhibition of some of the normal symptoms of grief.

* Delayed grief: the bereaved person put grief on hold for any reason.

* Conflicted grief: often seen when there is a dependent or ambivalent relationship with the deceased. Two common manifestations are extreme anger and extreme guilt.

* Chronic grief: the mourner continues to have an intense grief reaction for a long period of time that does not have any resolution. The bereaved person may feel unfinished (Rando, 1984).

According to Karaban (2000), complicated loss can be defined by the type of loss or by the circumstances around the loss. The types of death that are considered complicated or difficult are if there was a sudden or unexpected death, a violent death, if the death involved mutilation, if it is a child who dies, and if the death is the result of a prolonged illness.

Other losses that are complicated because of their nature are ambiguous losses, traumatic losses, and disenfranchised losses such as a child's grief and imprisonment. Also included is complicated loss that involves social stigma such as suicide, AIDS, and abortions or psychosocial death such as severe mental illness or addictions (Karaban, 2000).

Preventive Intervention Programs

Zambella & DeRosa (1992), and Heiney, et al. (1995), agreed that the major goal for a support program is to promote the child's normal grieving process and adjustment to the loss of a loved one. According to Zambella & DeRosa (1992), child support groups can be a useful surrogate support system for families when a parent dies, as death puts tremendous strain on the family's existing coping systems.

Both Zambella & DeRosa (1992) and Heiney, et al. (1995) have similar activities in which to engage the children. These activities encouraged the children to confront their loss. The programs included art therapy that promoted discussion, talking groups that encouraged discussion of feelings and that build relationships, memory projects, closure activities that involved writing and talking that encouraged the children to share memories of their deceased parent.

Heiney et al. (1995) offered a holiday program that focused on helping the child deal with the death around the time of important family holidays. The downside of both of these programs is that neither of them includes psycho-educational support groups for surviving parents. Baker et al. (1992) stressed the importance of psycho-education for adults who are involved with bereaved children to provide them with information about how children respond to grief. The intervention used in a cancer center research study described by Christ, Siegal, Mesagno & Langosch (1991) utilized a psycho-educational intervention for surviving parents that included an assessment of the bereaved children. This preventive intervention program did not include a child support group. A better preventive intervention program would include a psycho-educational intervention and a child support group intervention.

In Zambella & DeRosa (1992), the clinical impressions from their child bereavement support group indicated that there was a protective process that occurred in the support group. They suggested more research is needed on the outcomes of these prevention interventions.

Summary

The death of a parent is a major stress event for children and their families. This traumatic event can bring on serious psychological and social distress to bereaved children and their families. The surviving parents and children will go through the stages of grief in their own time frames. Children who are not supported in the early phases of grieving can develop serious emotional and behavioral problems that can lead to the development of some major psychiatric disorders.

The importance of early prevention support programs for surviving parents and bereaved children are of major importance in helping them adapt to their losses. Early prevention programs need to include psycho-educational groups for the surviving parents and support groups for the bereaved children. These structured programs can decrease the risk of complicated grief in bereaved families. More research studies are needed to validate the effectiveness of these early prevention program interventions.

Web Sites of Interest

Counseling for Loss & Life Transitions, http:// www.counselingforloss.com: Helpful information for counselors and parents.

The National Center for Grieving Children & Families, http://wwiu.dougy.org:

Information on grief for: parents, children, and counselors.

References

Baker, J., Sedney, M., & Gross, E. (1992). Psychological tasks for bereaved children. American Journal of Orthopsychiatry, 62(1), 105-116.

Black, D. (1998). Coping with loss: Bereavement in childhood. British Medical Journal, 326(7135), 913-933.

Bowlby, J. (1980). Attachment and loss (Volume 3). New York: Basic Books.

Congressional Record House Children Who Lost A Parent of Guardian on September 11, 2001, Must be Provided for; October 30, 2001. Retrieved on October 11, 2002, from http:// www.yale.edu/lawweb/avalon/sept_11 /cr_044.htm

Christ, G., Seigel, K., Mesagno, F., & Langosch, D. (1991). A preventive intervention program for bereaved children: Problems of implication. American Journal of Orthopsychiatry, 67(2), 168-178.

Dowdney, L., Wilson, R., Maughan, B., Allerton, M., Schofield, P., & Skuse, D. (1999). Psychological disturbance and service provision in parentally bereaved children: prospective case-control study. British Medical Journal, 319(7206), 354-357.

Geis, H., Whittlesey, S., McDonald, N., Smith, K., & Pfefferbaum, B. (1998). Bereavement and loss in childhood. Child and Adolescent Psychiatric Clinics of North America, 7(1), 73-85.

Heiney, S.P., Dunaway, C., & Webster, J. (1995). Good grieving - an intervention program for grieving children. Oncology Nursing Forum, 22(4), 649-655.

Johnson, J. (1999). Keys to helping children deal with death and grief, New York: Barren's Educational Series, Inc.

Karaban, R. (2000). Complicated losses, difficult death, California: Resource Publications, Inc.

Kubler-Ross, E. (1969). On death and dying, New York: Macmillian Publishing Company.

Mireault, G. & Bond, L. (1992). Parental death in childhood: Perceived vulnerability, and adult depression and anxiety. American Journal of Orthopsychiatry, 62(4), 517-524.

Rando, T. (1984). Grief, dying, and death, clinical interventions for caregivers, Illinois: Research Press.

Saler, L. & Skoinick, N. (1992). Childhood parental death and depression in adulthood: Roles of surviving parent and family environment. American Journal of Orthopsychiatry, 62(4), 504-516.

Sheldon, F. (1998). ABC of palliative care: Bereavement. Britisli Medical Journal, 376(7129), 456-458.

Silverman, P., Nickman, S., & Worden, W. (1992). Detachment revisited: The child's reconstruction of a dead parent. American Journal of Orthopsychiatry, 62(4), 494-503.

Silverman, P. & Worden, W. (1992). Children's reactions in the early months after the death of a parent. American Journal of Orthopsychiatry, 62(1), 93-104.

Steen, K. (1998). A comprehensive approach to bereavement. The Nurse Practitioner, 23(3), 54-68.

The Avalon Project at Yale Law School, September 11, 2001: Attack on America.

Weller, R., Weller, E., Fristad, M. & Bowes, J. (1991). Depression in recently bereaved prepubertal children. American Journal of Psychiatry, 148(11), 1536-1540.

Wolfelt, A. (1996). Healing the bereaved child. Colorado: Companion Press.

Worden, J. (1991). Grief counseling and grief therapy. New York: Springer Publishing Company.

Worden, J. (1996). Children and grief, iohen a parent dies. New York: The Guilford Press.

Zambelli, G. & DeRosa, A. (1992). Bereavement support groups for school-age children: theory, intervention, and case example. American Journal of Orthopsychiatry, 62(4), 484-493.

Kathleen M. Kirwin, MSN, APRN, CNS, BC and Vanya Hamrin, MSN, APRN, CNS, BC

Kathleen M. Kinvin, MSN, APRN, CNS, BC is a family psychiatric nurse practitioner at the Psychotherapy and Medication Consultation Private Practice In Wallingford, CT, and Vanya Hamrin, MSN, APRN, CNS, BC, is a program instructor, Yale University, School of Nursing, New Haven, CT.

Author contact: E-mail: k.kirwin@snet.net, with a copy to the Editor: Poster@uta.edu