pediatrics
February 2000, VOLUME105 /ISSUE 2

The Pediatrician and Childhood Bereavement

  1. Committee on Psychosocial Aspects of Child and Family Health

Abstract

Pediatricians should understand and evaluate children's reactions to the death of a person important to them by using age-appropriate and culturally sensitive guidance while being alert for normal and complicated grief responses. Pediatricians also should advise and assist families in responding to the child's needs. Sharing, family support, and communication have been associated with positive long-term bereavement adjustment.

The death of an important person in a child's life is among the most stressful events that a youngster can experience.1–3 Adults in the midst of their own grief often are confused and uncertain about how to respond supportively to a child.3,,4 When the death involves a parent or a sibling, the potential for an adverse response by the child is compounded.5 During such a crisis, the pediatrician can be an important source of education and support for a child and family.1

By already knowing something of the family interactions and individual coping skills, the pediatrician is in a position to help evaluate and understand a child's reactions and to advise and assist the family in responding to the child's needs.1–3 Awareness of the child's temperament and typical responses to stress can help the pediatrician counsel the child and family.2 Cultural and religious background are important considerations in dealing with the bereaved family.2,,6,7 Knowledge of previous significant losses and parent and child responses to them are helpful in understanding and predicting how a death may affect the child and family.2 Circumstances (eg, prolonged illness, sudden unexpected death, or violent death) are important additional considerations.6–8 In instances of disasters with multiple deaths, the pediatrician is likely to be called on as a resource by rescue teams, school personnel, and others. The pediatrician should describe to families and personnel the normal childhood emotional reactions to such an abnormal incident and offer support and counsel to the children and to the adults caring for them.9

The funeral services can provide even a young child with an important way to grieve a loved one if such involvement is supportive, appropriately explained, and compatible with the family's values and approach.2,,8 Children need to be prepared if they are to participate in the funeral process.12 The participation should be tailored according to the developmental level of the child. For instance, the younger child may have the process broken down into shorter, more manageable, intervals. A trusted person should be with a child to explain what is happening and to offer support.3Older children and adolescents may want to participate by speaking at the funeral or memorial service. Encouraging a child to commemorate loss through some form of participation, such as drawing pictures, planting a tree, or giving a favorite object, will promote inclusion in the process and provide a meaningful ritual.5

Recognition of one's own attitudes and reactions to death is essential for objectively and supportively counseling the family.1Pediatricians must realize that grief counseling is an emotionally demanding, time-consuming, and potentially frustrating endeavor.3The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version14 identifies diagnoses and conditions and may help the pediatrician evaluate the degree of severity of the child's behavior. Use of DSM-PC coding also may help the pediatrician deal with third-party payers. Referral to a mental health specialist or clergy (pastoral counselor) should be considered when the pediatrician believes that progress is not being made or would feel more comfortable having someone else work with the family.

RECOMMENDATIONS

  1. The pediatrician should provide support and anticipatory guidance for children and families who face death. The pediatrician is in a position to encourage open discussion of reactions, thoughts, and feelings in the family, thereby increasing the sense of mutual support and cohesion.

  2. The pediatrician must use age-appropriate and culturally sensitive guidance while being alert for normal and complicated grief responses. The ability to share, reliance on family members, and good communication have been associated with positive long-term bereavement adjustment.

    Committee on Psychosocial Aspects of Child and Family Health, 1998–1999

  • Mark L. Wolraich, MD, Chairperson

  • Javier Aceves, MD

  • Heidi M. Feldman, PhD, MD

  • Joseph F. Hagan, Jr, MD

  • Barbara J. Howard, MD

  • Ana Navarro, MD

  • Anthony J. Richtsmeier, MD

  • Hyman C. Tolmas, MD

    Liaison Representatives

  • F. Daniel Armstrong, PhD Society of Pediatric Psychology

  • David R. DeMaso, MD American Academy of Child and Adolescent Psychiatry

  • Peggy Gilbertson, RN, MPH, CPNP National Association of Pediatric Nurse Associates and Practitioners

  • William J. Mahoney, MD Canadian Paediatric Society

    Consultant

  • George J. Cohen, MD National Consortium for Child and Adolescent Mental Health Services

Footnotes

  • The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

REFERENCES

ADDITIONAL READINGS

  1. BU1.
  2. BU2.
  3. BU3.
  4. BU4.
  5. BU5.
  6. BU6.
  7. BU7.
Table 1.

Overview of Children's Concepts of Death

Table 2.

Range of Common Grief Manifestations in Children and Adolescents

Table 3.

Selected Books About Bereavement for Parents and Children*