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8 Strategies for Working with Grieving Children
10 CEUs 8 Strategies for Working with Grieving Children

Section 23
Childhood Grief: Effects and Adjustment

Question 23 | Answer Booklet | Table of Contents | Grief CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, MFT CEU

Social and Educational Adjustment
It would be reasonable to expect that emotionally and behaviorally disturbed children, or those experiencing psychiatric disorder, would show impaired social and educational functioning. Equally, a heterogeneousDisturbed Grief Strategies for Working with Grieving social work continuing ed outcome could be expected for a number of reasons. Both clinical experience and research interviews indicate that some bereaved children determine to do better at school as a form of tribute to their dead parent. Others report more difficulty in concentration, and distress, particularly when memories of their dead parent are evoked in school (Silverman & Worden, 1992a). Dowdney et al. (1999), using the Achenbach Teachers Report Form (Achenbach & Edelbrock, 1980), found that teachers of bereaved children rate them as being significantly less attentive than matched classroom controls. Whether this finding relates in any systematic way to attainment or school relationships is not discussed. In their community study of 125 children, aged 6 to 17 years, from 70 bereaved families, Silverman and Worden (1992a) suggest that children with greater degrees of affective distress out of school are more likely to experience poorer school performance and more unsatisfactory peer relationships. Distress in one context may be related to the expression of  distress in another, as shown by the correlation between parent and teacher reports in the study by Dowdney et al. (1999).

However, all studies of school performance share the common limitation of retrospective parental recall of child functioning prior to the death, and a reliance on indirect measures of educational attainment. Standardized measures of attainment have been infrequently employed. Combined with child differences in academic skills, competence, and response to parental death, these limitations mean that we can only conclude that outcomes will vary between children. Risk and protective factors, which singly or in combination may contribute to this heterogeneity, have not been the focus of these studies.

Duration of Effects
When bereaved children are emotionally or behaviorally disturbed by bereavement will this be a transient reaction, or does it persist over time? This question can most satisfactorily be addressed in longitudinal studies of bereaved children. However, such studies do not exist (Black, 1998). From the available literature on short-term outcome, however, two conclusions can be reached. First, children's grief reactions do attenuate with the passage of time. Crying, sadness, and dysphoria decline over the first year post death (Silverman & Worden, 1992a; Van Eederwegh et al., 1982). Second, where emotional and behavioral disturbance  is found, it can persist for up to 12 months after the death.

Van Eederwegh et al. (1982, 1985), gather data at two time points: 1 and 13 months after parental death. Although dysphoria declines significantly during that  time period, careful consideration of their findings suggests some evidence of persisting disturbance. Levels of dysphoria were still significantly higher than those found in controls at 13 months. Further, other symptoms such as abdominal pain, arguments with siblings, and a lack of interest in school showed a significant increase in frequency over the year of the study period. The collapsing of data gathered at different time points makes interpreting the results of this study difficult, but it seems that a persistent form of mild depression occurs in a proportion of children in this sample. In support of these findings, Dowdney et al. (1999) report no significant association  between levels of disturbance and time since death between 3 to 12 months post death.

The matter is, however, made more complicated by reports that child disturbance can apparently begin months after parental death (e.g., Elizur & Kaffman, 1982;Worden & Silverman, 1996). Grief and disturbance appear to fluctuate over time within and between bereaved children, such that children reported as not depressed at one follow-up time point, can be so at another (for descriptive data, see Elizur & Kaffman, 1982). The longer the passage of time from the death itself, of course, the harder it is to disentangle the effects of bereavement per se from other independent and unmeasured variables. Although it is tempting to ponder the possibility that parental death increases child vulnerability to later stressors or loss, this hypothesis has never been tested.

Influences on Child Outcome: Moderating and Mediating Variables
A number of factors have been cited as influencing child outcome following parental death (see Black, 1978; Geiss, Whittlesey, McDonald, Smith, & Pfefferbaum, 1998), although these findings rest upon both empirical reports and clinical case studies. One group of factors include those pre-existing variables that are not influenced by the death itself, such as the age and sex of the bereaved child. These can be regarded as moderating outcome. The second category contains mediating variables that exert their influence after the death. For example, these could include factors such as how grief is handled within the family, and whether the surviving parent develops mental health difficulties. Some variables, such as the type of death, could be included in either category, but is included here under moderating variables.

Moderating Variables Death-related variables
(1) Death by murder or suicide : Parental suicide and murder are relatively rare and systematic research in this area is sparse. Indeed, some studies specifically exclude children where parental death has been caused in this way (e.g., Fristad et al., 1993; Sanchez et al., 1994; Sood et al., 1992; R. A. Weller et al., 1991). The limited evidence available indicates that traumatic parental death is associated with particular forms of child disturbance. Black and Harris-Hendriks (1992) present a series of some 100 children referred to psychiatric services following the murder of one parent by the other, and describe the occurrence of PTSD symptoms amongst these children.

Only one systematic study of parental suicide has been undertaken (Pfeffer et al., 1997). These authors studied 16 community families, with children aged 5±14 years, where a parent or sibling had committed suicide 1 to 3 years previously. Both surviving parents and children were interviewed. Using the family as their unit of analysis, they report that 63%of families had children with CBCL internalizing scores of probable clinical severity ; and 37%had children showing moderate to severe symptoms of post-traumatic stress. In 25%of families, there was at least one child with both clinically significant features of depression and moderate to severe symptoms of PTSD. Indeed, no child reported clinically significant levels of depressive symptoms in the absence of moderate to severe symptoms of PTSD. Suicidal ideation had occurred in at least 1 child in 5 of the 16 families, although no child reported attempted suicide. However, as discussed earlier,  child suicidal ideation is not specific to traumatic parental death (R. A. Weller et al., 1991).

Suicide and murder are thought to complicate the child's bereavement response because of the likelihood of traumatic images associated with reports of the death or witnessing it (Pfeffer et al., 1997; Pynoos, 1992). The findings of both Black and Harris-Hendriks (1992), and Pfeffer and colleagues (1997) can, therefore, be regarded as consistent with those from the childhood post-traumatic  stress literature. Children who have experienced highly stressful events, particularly in a context where death occurs, are at risk of PTSD (Yule, 1994). Black and Harris-Hendriks report that most children with PTSD in their sample were present in the home when parental murder occurred. Comorbidity of depression and PTSD has also been found in studies of children where siblings have died from murder or suicide (Freeman et al., 1996). These children also described the conflict they experienced  when dealing with grief complicated by symptoms of PTSD and fear. Their reports indicate how striving to avoid painful and intrusive thoughts inhibited the expression  and resolution of grief, and family communication.

Expected or unexpected death: It has been suggested  that where the death of a family member is expected, anticipatory mourning may facilitate better post death adjustment in adults (Parkes, 1972), although the relationship   is not a straightforward one (Raphael, 1996).

There has been little investigation of the effects of expected versus unexpected death in children, although the issue has been considered in the literature on families where one member has a terminal illness. Siegel et al. (1992) reports that children (7 to 17 years) whose parents were in the terminal stages of illness displayed significantly higher levels of depression and anxiety than community controls. At follow-up, between 7 to 12 months after parental death, differences between the groups had become nonsignificant (Siegel, Karus, & Raveis, 1996). Although the study is limited by its concentration on potentially bereaved families participating in a hospital intervention program, it does suggest that where parental death follows a lengthy terminal illness, child disturbance may precede the death itself. Birenbaum finds a  similar effect in siblings when one child in a family has terminal cancer (Birenbaum, Robinson, Phillips, Stewart, & McCown, 1989). Unfortunately, high rates of family drop-out from the follow-up study subsequent to the child's death makes it difficult to assess whether, and for how long, sibling disturbance may have persisted.

Other studies assessing the effects of expected versus unexpected death are hampered by varying definitions of these terms. Some define expected death on the basis that families have prior knowledge of the likelihood of death,  with a minimum anticipatory period ranging from more than 1 day (Silverman &Worden, 1992a) to greater than 2 weeks (Kranzler et al., 1990). Other studies base the distinction upon the cause of death for example terminal illness or heart attacks (R. A. Weller et al., 1991). Whatever definition is employed, there is little evidence that either expected or unexpected death is associated with either the occurrence, or type, of subsequent childhood disturbance (Dowdney et al., 1999; Fristad et al., 1993;Kranzler et al., 1990; Sanchez et al., 1994; Sood et al., 1992; R. A. Weller et al., 1991).

Death-related variables whether a mother or father dies. Is child outcome influenced by whether it is a mother or father who dies ? The early literature indicates that this may be the case, and it has been suggested that an interaction between the sex of the child and that of the deceased parent moderates outcome. For example, Brown and colleagues report that girls under the age of 11 years who lost their mother were at higher risk of depression in adult life (Black, 1978; Brown et al., 1977). Inevitably, studies of parental death will be influenced by the differential death rates between men and women who are in the parenting age range. Epidemiological data on parental death in childhood indicate that fathers die twice as frequently as mothers. Researchers are likely, therefore, to encounter more surviving mothers than fathers.

In addition, surviving fathers tend to be less willing to participate in research and}or to seek help when distressed (Gersten et al., 1991). This gender imbalance  makes it hard to examine the effects of the death by the sex of the deceased, particularly in the small samples usually employed.

Van Eederwegh et al. (1982) suggest the possibility of a link between the death of a father and severe depression in boys and older children, but only six children were so classified. R. A. Weller et al. (1991) suggest that the issue may be confounded by surviving mothers reporting more depressive symptoms in their children than fathers do. Given these factors, it is not surprising that no significant associations are reported between the sex of the deceased and child psychiatric disorder, somatization, or psychosocial functioning (Fristad et al., 1993; Sanchez et al., 1994; Sood et al., 1992; R. A. Weller et al., 1991).
- Dowdney, L.; Childhood bereavement following parental death; Journal of Child Psychology and Psychiatry; Oct 2000; Vol. 41.

Personal Reflection Exercise #9
The preceding section contained information about the effects and adjustment in childhood grief. Write three case study examples regarding how you might use the content of this section in your practice.

According to Freeman et al., what is inhibited by children dealing with grief complicated by symptoms of PTSD avoiding painful and intrusive thoughts? Record the letter of the correct answer the Answer Booklet.

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