By the age of 15, an estimated one in 20 children has suffered the loss of a parent. Additionally, of the approximately 73,000 annual pediatric deaths in the United States, it is estimated that 83% have surviving bereaved siblings http://bit.ly/29jFSXR.
These bereaved children require special attention and support: a key role that pediatricians can and should play. To do so, one must understand what a child comprehends, how a child grieves, what constitutes maladaptive grief and the necessary interventions to ensure a child is able to accommodate her grief into her daily life and development.
To understand death, experts agree that three sub-concepts must be understood: death’s irreversibility, that it happens to all (universality) and that it renders someone incapable of function (non-functionality).
Children gain emerging understanding of these concepts typically starting at age 6, and many have full comprehension by age 10. The rate by which a child gains understanding may be impacted by his cognitive ability, exposure to death and primary caregivers’ openness to discussing death.
Grief manifestationsMany children have full comprenehsion of the concepts of death by age 10.
Grief demonstrations vary by age. Toddlers will be egocentric and often have bursts of expression through play. School-age children will seek answers often through repetitive questioning and may appear emotionally blunted as they seek to deny the universality of death.
Pre-adolescents ask concrete questions regarding causation, while teenagers utilize a fully functional death comprehension through abstract thought, often struggle with the injustice of a death and seek support through their peers.
Grief work is the bereavement process of assessing, accommodating and managing one’s grief over time. For children who have incurred a loss, this is neither a static nor a one-time process. Rather, as a child proceeds through his developmental stages of life, a re-capitulation of grief work ensues so as to accommodate the loss in the context of what the child understands about life and death.
Often a child needs assistance with “the re-organization of roles, routines, rules, responsibilities and relationships within her family unit” (Carr A. (2005). Handbook of Child & Adolescent Clinical Psychology. London: Routledge) to best accommodate the grief into her new life.
Bereaved children may be at risk for maladaptive grief such as depression (present in 10% of bereaved siblings), prolonged grief disorder (as high as 50%) or post-traumatic stress disorder (10%-50%). Risk factors include being an older child at time of death, lack of personal resiliency skills or poor surrounding protective attributes such as a home with open expression of sadness and a positive parenting style (Morris A, et al. J Pain Symptom Manage. 2016;51:60-70).
Role of the pediatrician
Pediatricians play an integral role as a family navigates a death. Their presence, even if silent presence, is a gift long treasured by bereaved parents and children.
Educating parents that bereaved children as young as 6 comprehend aspects of death and encouraging open communication are imperative to optimize a home’s protective attributes to encourage needed grief work.
Finally, continuing well-child visits with bereaved siblings, screening for maladaptive behaviors or grief and referring to mental health resources in a timely fashion can make a significant impact on the child’s health and long-term well-being.
Dr. Humphrey is a member of the AAP Section on Hospice and Palliative Medicine.