Listen to thisNone of us would deny the profound impact that a death within a family has on its members. There has been an increasing awareness and understanding of the grief and mourning processes that bereaved adults experience. However, the surviving children have often been neglected and even ignored. The reasons for this are twofold: firstly, we cannot bear to think that they too could be experiencing pain and suffering; and secondly, we feel that children are not affected and that life goes on for them. In this paper I am hoping to show you that children are indeed deeply affected by death albeit in different ways to adults. As family therapists we have to be aware of children's needs. There are certain situations that call on us to have specialised knowledge. I believe that bereavement is one of these and that a system’s model alone is insufficient to really help us understand these families. I am thus deliberately focussing on the child within the family.
Children's understanding of death
At some point each child must learn about death. A century ago this knowledge was part of life and no child grew up without the experience of at least one death-bed scene. However, Western society has become “death denying” and death has become a “taboo topic”, with adults being reluctant to allow discussion around it. But children do think a great deal – both about the beginning of life, as well as its end. The understanding of death is complex involving several interactive processes and I shall not elaborate on these here.
The Experience of Bereavement
Three definitions will be helpful:
Bereavement: The reaction to the loss of a close relationship through death.
Grief: The overt emotional response to the loss.
Mourning: The psychological processes that occur in bereavement. This means the individual’s effort to accept the fact in the external world and to effect corresponding changes in the inner world (Anna Freud). The psychological bonds that bound the bereaved to the deceased gradually have to be undone.
Phases of bereavement
Bereavement reactions have been divided into different stages. The phases described by Kubler-Ross (1968) (denial, anger, bargaining, depression and acceptance) fit more into the reactions seen when confronted with the news of a fatal illness. Bereavement reactions per se can also be viewed according to Bowlby’s (1960) model of attachment separation theory. John Bowlby advances the thesis that the sequence of responses to separation seen in young children is characteristic of all forms of mourning. The infant’s attachment to his primary love object, usually the mother, is mediated by instinctual response systems. From the age of six months onwards the child reacts to the separation from his mother with a series of responses manifested by Protest, Despair and Detachment. Bowlby regards these as being parallel to the phases of mourning.
Phase One
The urge to recover the lost object is likened to the phase of Protest. The bereaved weeps, searches and yearns for the deceased. Anger at having been deserted is expressed. The response system is focussed on the lost object and the aim is to reverse the loss.
Phase Two
The phase of Disorganisation is similar to the Despair that the child experiences when the mother does not return, despite his strenuous efforts to recover her. The response systems are no longer focussed on the lost object, since there is now a gradual realisation that it may be permanently absent. Consequently behaviour becomes disorganised and the effect of depression predominates.
Phase Three
Two outcomes are possible: Reorganisation or Detachment. If the first two phases have been allowed to develop and the affects been worked through, the third phase completes the work of mourning in that reorganisation takes place. New patterns of behaviour, adapted to new objects have been developed.
Detachment occurs when the mourning process has not been negotiated successfully and this represents a pathological outcome. While from the outside it appears as though the person has withdrawn his libido from the lost object, the yearning for it persists unconsciously and is being strongly defended against. The question arises, do children mourn according to these processes and patterns? Viewpoints on this issue differ considerably. As described above, Bowlby proposes that infants from six months onwards are capable of mourning as adults do. On the other extreme there are those therapists who have concluded that mourning is not possible during childhood (Deutsch, 1937 and Wolfstein, 1966). Between these two positions are clinicians who have observed mourning to occur during childhood. Robert Furman draws attention to the fact that it is important to distinguish between a child not mourning and his apparent incapability of mourning. He considers children from the age of three and a half to four years as having the mental functions required for the work of mourning to occur. There are, however, important differences between the mourning of children and adults and these will be mentioned briefly.
Characteristics of the young child's bereavement reactions
The death of a relative constitutes a developmental interference which may lead to distortion of development and symptoms of a diverse nature. Unlike the adult, the child is in the midst of develop mental processes. The child cannot afford to suspend these, and mourn, and then start where he left off. Instead the child has to accommodate his bereavement reactions within his developmental needs and it is this that clouds the picture and leads to complications. Because of the child's low tolerance of psychological pain and because of his curiosity, mobility and flexibility of interest and attention, he exhibits a “short sadness span”. The protracted mourning as seen in the adult, cannot be sustained. This accounts for the seeming lack of feeling on the part of the child. Another characteristic is the child's dependency on adults and familiar surroundings. Children are only able to show their mourning reactions if these dependency needs are being met. If the bereavement coincides with other stressful experiences, such as moving house and losing the nuclear family structure, the child's ego is overwhelmed. These children do not show a mourning reaction, simply because they have to reserve whatever energy they have to cope with and survive the external stressors. The child's incomplete, immature ego development accounts for some of the “atypical” (from the adult’s point of view), reactions they exhibit. The denial of the painful loss, the inadequate reality testing the concrete thinking and egocentricity are illustrated by the child's reaction to the loss (by suicide) of her mother. Instead of grieving for her mother in a direct way, she was haunted by her mother’s ghost for three years. The ghost followed her, frightened her, but also provided her with a link to the deceased mother. It required two years of individual psychotherapy to undo these bonds and to work through the loss.
Main Features of Children's Reactions to Loss
The young infant
The young infant reacts to change in the quality of his sensory
experience, e.g. a new mothering figure will handle and hold the infant
differently than the original mother and it is this difference that the
baby picks up. Similarly, a mother who is grieving or who is depressed
because of a loss, will be less able to respond to her infant and again
it is this subtle difference that causes the child distress.
The older infant
He or she is aware of the mother as a whole person and will respond to
her loss by protest, despair and detachment as described by Bowlby.
The pre-school child
These children exhibit variable behaviour. They may not seem to
understand the death fully and are likely to ask again and again about
it. There may be regression and clinging behaviour and a return to
earlier modes of functioning, e.g. soiling. The child may become
aggressive, naughty and wild and at the same time show heightened
attachment to adults. He or she may also idealise the deceased and have
fantasies of reunion.
The young school child
These children may resort to denial of the reality of the death and
their own feelings about it. There may be excessive guilt such as the
six-year-old boy who lost his father and conceded that it was in a way
quite good that his father died as he could now have his mother all to
himself and sleep in her bed. The child may also have fear about the
physical safety of the surviving parent and show distorted concepts of
illness and death, as well as distorted attitudes towards doctors,
hospitals and God.
The older school child
Older children may show many of the above behaviours and concerns of the
younger child. There are, however, a few outstanding features: Fear of
their own death may lead to phobic behaviour and hypochondriasis. They
may become fearful of sleep, darkness and look for symptoms of disease
in their own bodies. These children may also compensate for their
feelings of helplessness and dependence by having an independent and
coping exterior, by being bossy or showing compulsive care-giving to
younger siblings. Teachers are particularly important in this age group.
The child may perceive the school situation as a safer forum for him
than the emotionality at home.
Family functioning is always disturbed, either temporarily, or also often permanently. Parental mourning has a particular impact on the following areas of family functioning:
What I have just described are normal reactions if they are temporary up to 6-8 months after the death and if they do not interfere with the child's general functioning.
Pathological bereavement reaction in children
These are defined by two criteria:
(a) the presence of persistent clinical symptomatology and
(b) the need for psychological care.
In an Israeli study where 25 kibbutz children who had lost their fathers were followed up, it was found that 50% had severe and persistent behaviour problems sufficient to be called “pathological bereavement reaction” (6, 18 and 42 months after death). Similarly, in the UK, Dora Black (1984) found that one-third of bereaved children showed behaviour problems one year after death. My own findings are as follows: thirty one children of 25 families were seen within a three-year period with ages ranging from 3-5 years. The presenting symptoms varied tremendously as did the psychiatric diagnoses which were as follows:
From this it can been seen that the spectrum of symptomatology is wide unlike the picture with bereaved adults who can be more easily fitted into one or two categories.
Helping the bereaved child
Each death, each family and each child is unique so that generalisations are impossible. However, there are some guiding principles: “Psychological immunisation” has been described by Kliman (1968). This concept is analogous to the one in physical medicine, namely, a low dose of anxiety which the child is exposed to in order to prepare him/her for the difficulties of life. A “trial action” of exposure to death and burial can be rehearsed in various ways with children, such as the death of a pet, distant friend or relative. Talking about what happened, allowing the child to bury his pet, all these are important steps towards showing children that sadness can be tolerated and death can be integrated into life.
Let us now move from a death that is more distant and less threatening to a death in the family situation. When a parent or sibling is dying, it is helpful to maintain personal contact between the sick person and the child for as long as the person has not drastically altered in appearance or in ability to communicate. It is also important to keep communication open and direct, i.e. to answer the child's questions about the cause of death and what happens to dead people. In a study of bereaved families Siegel (1985) found only 59% of the parents even mentioned the subject of death in the family to their children under the age of 16. Twenty percent told children fairytales about death and another 20% told children something about what was consistent with their own belief, but did not include the concrete important facts about death. This, more than anything else, points to the defensiveness of adults when it comes to the subject of death. a Once the person has died, it is important for the child to see the deceased, unless disfigurement is severe. Viewing the dead helps to allay fantasies of death and gives the child the last concrete opportunity to say goodbye. Similarly, the attendance at funeral ceremonies should include the children if they so wish and most do. A study again by Black (1984) showed that funeral attendance was related to increased crying but less, shorter lasting deviant behaviour. However, it must be stressed that children need during such limes an adult who can support them and remain in touch with their feelings. Unsupported children could become severely frightened and confused. After the funeral and for the time that follows, visits to the grave serve as important reminders of the finality of death. Photographs and other objects are of importance during the period of remembering. One should not try to forget about it, but rather reminisce, talk and “give sorrow words” and allow oneself and the child to feel the sadness.
Much of this is done naturally by many families, but there are just as many who cannot communicate and express their feeling, and cannot allow their children to do so. These are often the families where the children become the “identified patients” and help is then sought from mental health professionals. But even mental health professionals are often not sensitised sufficiently to the impact of bereavement on children. In the sample I quoted seven children were seen initially without diagnosis and were discharged only to be re-referred years later with serious psychiatric disturbances requiring long-term intervention.
Indications for management
Of the sample of children seen personally the following pattern in psychiatric management emerged. In the initial stage the family should always be seen together. This accounts for the relatively large proportion of the crisis intervention in my sample. When the children have not been told about the cause of death, they need to be told but in a family context and preferably by the surviving parent and not the professional. The parent may often need prior preparation and support in order to do this difficult task. Family therapy is indicated when the main difficulties lie with maladaptive ways of communicating and expressing feeling. It has been advocated as being the most effective way of preventing subsequent behaviour problems in children (Black, 1984). However, there are certain situations that call for the lengthy process of individual play therapy for the child. The criteria used for starting individual therapy are as follows:
When the child has been exposed directly or indirectly to excessive violent sensory stimuli these first need to be dealt with. Clearly this is a task impossible to demand of a surviving parent and often children do not have the means to put such images into words. In the case of a picture done by a boy whose younger sister was raped and murdered, he had great difficulty in verbalising his thoughts and feelings, but had an intense need to draw. He drew a collection of weapons and the perpetrator had a case of goodies with which he lured the frightened monkey away.
In summary, I would like to reiterate that the child's reaction always needs to be viewed within the context of the child's developmental level as well as his external circumstances. The child's grieving and mourning need to be encouraged so that the loss can be integrated. If insufficient attention is paid to this necessity, the end result may be a disturbed child or even adult. I would like to make a plea for early intervention: The first three categories, i.e. unnatural causes of death, the extent of the child's involvement in the death, and multiple death, warrant psychiatric management even in the absence of symptomatology in the child. In other cases intervention should be on a family level, with careful monitoring of the bereaved child and its adjustment and progress. Should there be any doubt about the latter, referral to a child psychiatric unit is not only appropriate, but in fact of utmost importance.
Bibliography
Black, D. and Urbanowia, M.A. Bereaved children “Family interaction. In Stevenson, J.E. (ed). Recent Research in Developmental Psychopathology. Pergamon Press, 1984.
Bowlby, J. Grief and mourning in infancy and early childhood. Psychoanalytic Study of the Child, 15, 1960, 9-52.
Elizur, E. and Kaffman, M. Children's bereavement reactions following death of the father. Journal of American Academy of Child Psychiatry, 21, 1985 474-480.
Freud, A. Discussion of Dr John Bowlby’s paper. Psychoanalytic Study of the Child, 5, 1960, 5362.
Kliman, G. Psychological Emergencies of Childhood. Grune and Stratton, 1968.
Kubler-Ross, E. On Death and Dying. McMillan, New York, 1970.
Maurer, A. Maturation of concepts of death. British Journal of Medical Psychology, 39, 1966, 35-41.
Nagero, H. Children's reactions to the death of important objects: A developmental approach. Psychoanalytic Study of the Child, 25, 1970, 360-400.
Raphael B. The Anatomy of Bereavement. Basic Books Inc., New York, 1983.
Siegel, B. Helping children cope with death. American Family Physician, 1985.
Speece, M.W. and Brent, S.B. Children's understanding of death: A review of three components of a death concept. Child Development, 55, 1984, 1671-1686.
Wolfenstein, M. How is mourning possible? Psychoanalytic Study of the Child, 21, 1966, 92-123.
This feature: Berg, Astrid. (1990). The Bereaved Family; the Child's Perspective. The Child Care Worker. Vol 8 (1). pp. 3-5
