An adolescent comes in for a checkup before beginning college out of state. Both her mother and her maternal uncle died during the early part of the COVID-19 pandemic. The visit is the day after Mother’s Day, and she mentions how difficult the holiday was for her. She regrets not being able to say goodbye to her mother while she was in the hospital and that only few immediate family members could attend the funeral. Although she hasn’t told her father yet, she is considering withdrawing from college. She doesn’t want to leave her dad alone at home or risk being away if something happened to him.
Later that day, you see another adolescent who attends a high school in a nearby community that is marginalized by discrimination and systemic racism. When you ask him about a classmate who died by suicide, he says he didn’t know him, but it’s “no big deal anyway.” He shares that two of his friends died this year, and an aunt who had been his primary caregiver died in childbirth as well. The family believes her death was the result of the delay in obtaining obstetrical care and the poor quality of the health care facility. He doubts he could talk with a school counselor about these losses because of inadequate professional staffing. He doesn’t have any plans after high school.
The COVID-19 pandemic resulted in a staggering number of deaths. Many children had to deal with cumulative losses and limited supports outside the home to assist or comfort them. The unique characteristics of the pandemic sometimes resulted in prolonged or otherwise complicated grief, which some children still are dealing with today.
Similarly, children in many marginalized communities face cumulative losses and often receive only limited supports outside of their families.
The AAP clinical report Supporting the Grieving Child and Family has been updated with new content on the unique characteristics of bereavement due to the COVID-19 pandemic, as well as the extra challenges faced by grieving children in minority or otherwise marginalized or disadvantaged communities.
As with the earlier version of the clinical report, it underscores how pediatricians are in an excellent position within a patient-centered medical home to offer support to grieving children and anticipatory guidance to their caregivers.
The report, from the AAP Committee on Psychosocial Aspects of Child and Family Health and the Council on Children and Disasters, is available at doi.org/10.1542/peds.2024-067212 and will be published in the July issue of Pediatrics.
Encouraging conversations, providing support
Patients and families may be reluctant to talk about deaths of family members and friends unless pediatricians let them know they are interested in hearing about losses and other major life changes. The clinical report offers strategies for how pediatricians can open the door to and approach conversations with bereaved patients and families.
It also reviews children’s developmental understanding of death from infancy through adolescence; experiences of guilt and shame; secondary losses (e.g., change in lifestyle, loss of shared memories, decreased sense of safety); grief triggers and anniversary reactions; cultural sensitivity; and working with schools.
Pediatricians can provide assistance and support in multiple areas, including:
- helping children understand what has occurred and the short- and long-term implications of the loss;
- identifying grief reactions such as guilt, shame, fear, anger, worry or depressive symptoms that should prompt additional exploration and possible referral;
- offering support to minimize distress and promote resiliency;
- providing reassurance to children who become fearful about their own health or the health of family members;
- providing advice on how to support children’s attendance at funerals and other memorial activities; and
- referring families to local resources for additional and ongoing services.
Children experience grief in response to other losses, such as separation from parents due to deployment, incarceration, deportation or divorce and psychological absence from the family because of mental health, substance use or chronic illness. Much of the report’s practical advice may be applicable, with modification, to these loss situations.
Importance of self-care
A relatively modest effort by pediatricians to provide compassion and support can reduce the amount of time grieving children feel confused, isolated or overwhelmed and thereby have a meaningful and lasting impact. But it is challenging to witness the distress of grieving children.
The clinical report addresses the importance of professional self-care for pediatricians who provide this critical support to grieving children and their families with recommendations on how to minimize the risk of compassion fatigue.
Dr. Schonfeld is a lead author of the report and a member of the AAP Council on Children and Disasters Executive Committee.
