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Grief is a normal and natural occurrence in life that can stem from various situations such as a loss of a loved one, a job, a move, or anything that causes a person to mourn. When a person experiences grief there is a variety of emotions that may cause the inability to carry on with normal activities. It may leave a person feeling numb and dissociated from life. Since grief is a personal experience and is a process that can not be controlled, it is hard to determine how long it will last. For some, it may last a couple of months and for others, years. Grief can occur in adults as well as children as it is not biased against age. (‘What is grief?’, n.d).
Grief usually ceases or the severity is lessened as time passes. However, when it is a constant and the intensity of it over time remains the same, causing a person the inability to continue and function normally, the grief may have evolved into Persistent Complex Bereavement Disorder (‘What is grief?’, n.d). This type of grief according to the proposed diagnosis criteria in the DSM-5 last more than 12 months in adults and more than 6 months in children (American Psychiatric Association, 2017). When this occurs the grief can trigger preexisting mental disorder or it can cause other psychiatric disorders to emerge (Kaplow, Saunders, Angold, & Costello, 2010).
Many studies have researched the impact grief has on adults after the death of a loved one, however, very limited studies have been conducted to include how children are mentally impacted after the loss of a loved one especially a parent. Statistical data shows that in the United States 1 in 20 children will experience the loss of a parent before the age of 18, and about 4% of children living in western countries will lose a parent during their childhood (Dyregrov & Dyregrov, 2013).
Currently, over 153 million children are orphaned worldwide (Children’s Statistics, n.d.). Grief in children after the death of a parent can be persistent and debilitating causing long term effects well into adulthood. Grief in 80% of children is usually resolved within a year of when the death occurred. The child is able to resume a life similar to before the loss. However, 20% of children who lose a parent during childhood will be severely impacted. (Stikkelbroek, Bodden, Reitz, Vollebergh, & Baar, 2015). The impact can depend on a variety of existing factors, such as the parents cause of death, the childs current environment, and any existing mental health issues occuring with the child or in the family (Kaplow, Saunders, Angold, & Costello, 2010).
Concerning children there is no clear definition of what Persistnat Complex Berevemnt is as compared to normal grief, as there is not separate proposed criteria in the DSM-5. However, children will express signs through their behavior. The symptoms go beyond crying or being sad, as these are typical when a death occurs. The symptoms are more severe. The child is unable to move past death and may exhibit intense feelings of anger, lack of concentration, nightmares, academic problems, and inability to make future plans. The reminder or memories are not of joy but are traumatic. There is no acceptance or reality of the loss. The child can not reconcile with the death or find meaning in it. It is also difficult to form or become engaged in other nurturing relationships with adults. The child experiences arrested development, unable to live the life that once was before the death occurred (Dyregrov & Dyregrov, 2013).
This type of bereavement also manifests differently depending on the age of the child. Preschool to school-aged children tend to exhibit signs by exaggerating fears, engaging in traumatic play, and aggression. They also tend to detach themselves from other adult caregivers. Adolescents will display or engage in risky behavior, can have suicide ideation, have the inability to recount the death of the parent, and are unable to plan or set goals for the future. (Dyregrov & Dyregrov, 2013). The longer the grief lasts the more likely the childs cognitive, emotional, physical and social well-being will be impacted (Melhem, 2011).
Persistent Beremvent is most likely to occur in children that are predisposed to mental disorders, are from a lower socioeconomic background, or have grown up in a negative environment where drug abuse and criminal activity occur. Children coming from these backgrounds are more likely to experience separation anxiety, depression, and exhibit conduct disorder at a higher right after the death of a parent (Kaplow, Saunders, Angold, & Costello, 2010)
Family or personal history of psychiatric disorders are also more likely to cause the child to suffer mentally after a parent dies (Melhem, 2011).. Studies have also revealed how a parent passes can also cause long-lasting grief and psychiatric problems to occur. When a parent dies from external causes such as suicide, homicide or a sudden accident as compared to natural causes, the rate of suicide and depression severely increases. When suicide is the cause of death a child is 82 % more likely to commit suicide than a parent who died from natural causes. The rate is more significant when death occurs before the child reaches the age of 6 and males are at a higher risk than females. Suicide has been seen patients even up to 25 years after the parent’s death. (Guldin, et al., 2015).
Just as there is an increased risk of suicide due to external factors and existing problems, studies have also shown that there is a higher rate of 70 to 100% increase of depression when prior mental health issues and external factors are present. Hospital admissions are higher for men and women after the death of a parent even years after their parents passing. Depression rates also tend to be higher when the death of the parent occurs at a younger age compared to that of a teenager. Outpatient care for depression tends to be higher as well, 11% of females and 8.9 percent for males will seek out some kind of outpatient care for depression due to grief (Berg, Rostila, & Hjern, 2016).
The post-death family environment is also a predictor of a child’s mental health. A child is more vulnerable to suffering from depression when the surviving parent has a mental disorder such as depression or bipolar disorder. The caregiver’s mental well being plays a significant role in how well the child will cope. The increase in depression is likely when the grief for the surviving parent is still debilitating after 9 months (Berg, Rostila, & Hjern, 2016).
The way a child is allowed to grieve will also determine if the child will recover, or will have a negative lasting effect that will lead to mental illness. Children are often considered to be resilient and are not given the necessary care. Therefore they are often ignored or forgotten and left to internalize using their own coping mechanisms. When this happens children will have a delayed reaction to the grieving process. Another event or death can trigger grief, and the suppressed grief can manifest later in other psychological disorders such as depression or anxiety (Shortell, n.d)
The majority of children who have lost a parent are able to grief and resume normal life. However, those who can not due to other contributing factors have a higher risk of mentally suffering and have negative long-lasting effects (Stikkelbroek, Bodden, Reitz, Vollebergh, & Baar, 2015). In order, to combat the grief and help the bereaved child from becoming stuck in grief, there are a variety of interventions that may help, however, the research is lacking as to whether they are effective or not.
The first type of intervention is early intervention. Because children who suffer the loss of a parent have a higher rate of a mental disorder or lasting effect when certain factors are present intervention is key. If the death of a parent is eminent because of an illness allowing the child to seek out early treatment will be beneficial to their mental health. Children who already suffer from depression, anxiety, or aother mental health issues will need to begin the grief process earlier in order to not exaceberae their present condition (Kaplow, Saunders, Angold, & Costello, 2010).
Two additional types of therapy that are being explored in an ongoing research study that started in 2014 to find an effective therapy for children suffering from grief are Grief Help Therapy and Support Therapy. Grief help therapy involves attending 9 sessions and includes completing five parts in a workbook that includes Who died? What is grief? cognitive restructuring, maladaptive behaviors, and moving forward with loss? At the end of the nine-session, the skills learned are reviewed, summarized, and written down. The parents review the information from the workbook with the therapist and the child. The surviving parent will also receive 5 sessions that will focus on the childs grief and not the problems of the parent. This will allow the continuation of therapy at home. It is also encouraged that the surviving spend more time with their child to develop better communication (Spuij, Prinzie, Dekovic, Bout, & Boelen, 2013). Support therapy also includes 9 sessions for the child and 5 for the surviving parent. It does not involve any workbook or homework. This therapy is divided into three sections. The first section identifies difficulties occuring in the childs everyday life. The child is also encouraged to express these feelings in any way that is comfortable. Section two, the child and the therapist review the thoughts of the child and it is decided how these thoughts will be explored either through detail talk or play. In section three, the child and therapist speak or play out how they will say goodbye when therapy has come to an end. Counseling sessions with the parents are planned for every two weeks and solutions for helping the child at home are discussed (Spuij, Prinzie, Dekovic, Bout, & Boelen, 2013).
Another therapy to consider that has had success in treating other conditions in children and is empirically backed up by data and research plays therapy. A meta-analysis published in 2014, showed the effectiveness of this therapy in children 8 years old or less. When comparing pre-treatment and post-treatment symptoms the children had made a 50% improvement compared to those who did not receive play therapy. This type of therapy has proven to work in children because children thinking to tend to be concrete and they often have a hard time expressing their emotions verbally. Play therapy allows them to demstrote their feelings and emotions through their actions rather their spoken words (Lin & Bratton, 2015).
Lastly, a possible therapy to treat children with persistent bereavement is Music therapy. According to the American Music Therapy Association, Music therapy is evidence and art-based health profession which uses music experiences within a therapeutic relationship to address clients physical, emotional, cognitive, and social needs It is considered a safe treatment and can help people who are unable to communicate through spoken language. It tends to focus on the client and can be easily incorporated into treatment when proper training as occurred. Music therapy has shown to help mood, stress, anxiety, social skills, and overall quality of life in children and adolescents. There are limited studies but the current is evidence suggests that it is an effective treatment especially when combined with other forms of therapy. (Stegemann, Geretsegger, Quoc, Riedl, & Smetana, 2019)
Most children who lose a parent will recover and not have any long term lasting mental health effects. However, 20% of children and adolescents will be greatly impacted will be based on s limited studies showing a correlation between Persistent Complex Bereavement manifesting in children and adolescents when preexisting mental conditions exist, certain environmental factors, and the cause of death of the parent. When these factors exsist the child is more likely to suffer from depression, anxiety, suicidal ideation, and other mental health issues. More research is needed in this area to explore how preexisting issues can cause more mental health issues as well as interventions that are effective in treating grief when other factors are present.
References
- Addressing grief and fostering resilience in children by Lanise Shortell. (n.d.). Retrieved from http://www.icpcn.org/addressing-grief-fostering-resilience-children-lanise-shortell/.
- Berg, L., Rostila, M., & Hjern, A. (2016). Parental death during childhood and depression in young adults – a national cohort study. Journal of Child Psychology and Psychiatry , 57 (9), 10921098. doi: 10.1111/jcpp.12560
- Children’s Statistics. (n.d.). Retrieved from https://www.sos-usa.org/our-impact/focus-areas/advocacy-movement-building/childrens-statistics.
- Dyregrov, A., & Dyregrov, K. (2013). Complicated Grief in ChildrenThe Perspectives of Experienced Professionals. OMEGA – Journal of Death and Dying , 67 (3), 291303. doi: 10.2190/om.67.3.c
- Guldin, M.-B., Li, J., Pedersen, H. S., Obel, C., Agerbo, E., Gissler, M., & Vestergaard, M. (2015). Incidence of Suicide Among Persons Who Had a Parent Who Died During Their Childhood. JAMA Psychiatry , 72 (12), 1227. doi: 10.1001/jamapsychiatry.2015.2094
- Kaplow, J. B., Saunders, J., Angold, A., & Costello, E. J. (2010). Psychiatric Symptoms in Bereaved Versus Nonbereaved Youth and Young Adults: A Longitudinal Epidemiological Study. Journal of the American Academy of Child & Adolescent Psychiatry , 49 (11), 11451154. doi: 10.1016/j.jaac.2010.08.004
- Wardecker, B. M., Kaplow, J. B., Layne, C. M., & Edelstein, R. S. (2017). Caregivers Positive Emotional Expression and Childrens Psychological Functioning after Parental Loss. Journal of Child and Family Studies , 26 (12), 34903501. doi: 10.1007/s10826-017-0835-0
- What is grief? (n.d.). Retrieved from https://www.mayoclinic.org/patient-visitor-guide/support-groups/what-is-grief.
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