PEDIATRICS Vol. 105 No. 2 February 2000, pp. 445-447

AMERICAN ACADEMY OF PEDIATRICS:
The Pediatrician and Childhood Bereavement

Committee on Psychosocial Aspects of Child and Family Health

	ABSTRACT

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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 child should be told about a death honestly and in language that is developmentally appropriate. When advising an adult about informing the child of the death, the pediatrician needs to be aware that a child's concept of death varies with age (Table 1) and needs to be able to tailor the specific advice given to a parent.^3,5,10 The family can be reassured that their showing of feelings, such as shock, disbelief, guilt, sadness, and anger, is normal and helpful.² A bereaved parent or other close family member who shares these feelings and memories (eg, with pictures and stories) with a child reduces the child's sense of isolation.^5,11 Children need reassurance that they will be cared for and loved by a consistent adult who attends sensitively to their needs. In addition, they must be assured that they did not cause the death, could not have prevented it, and cannot bring back the deceased.^1,5,8 Parents should be encouraged to continue family routines and discipline.^2,8,12

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.³ Older 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

Grief for a child is a process that unfolds over time. The initial shock and denial of death may evolve into sadness and anger that can last for weeks to months and eventually end, in the best of circumstances, with acceptance and readjustment.¹³ Some children may seem emotionally unmoved, thus causing concern to family members.^5,8 It is important for the pediatrician to be aware of the range of manifestations of childhood grief (Table 2) and to be alert to prolonged or severe behavior change that signals the need for more intensive intervention.^1,4,8 A number of age-appropriate books can be read by or to a child as support for understanding and dealing with the grieving process (Table 3). The pediatrician should remain alert to the resurfacing of the child's concerns at the anniversary of the death, at holidays, or at times of other losses as the child progresses through subsequent developmental stages.^5,11

Recognition of one's own attitudes and reactions to death is essential for objectively and supportively counseling the family.¹ Pediatricians must realize that grief counseling is an emotionally demanding, time-consuming, and potentially frustrating endeavor.³ The 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

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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

Top Abstract Recommendation References

1. Brent DA A death in the family: the pediatrician's role. Pediatrics 1983; 72:645-651 [Abstract/Free Full Text]
2. DeMaso DR, Meyer EC, Beasley PJ What do I say to my surviving child? J Am Acad Child Adolesc Psychiatry 1997; 36:1299-1302 [CrossRef][Medline]
3. Siegel BS Helping children cope with death. Am Fam Physician. 1985; 31:175-180 [Medline]
4. Mandell F, McAnulty EH, Carlson A Unexpected death of an infant sibling. Pediatrics 1983; 72:652-657 [Abstract/Free Full Text]
5. Gibbons MB A child dies, a child survives: the impact of sibling loss. J Pediatr Health Care 1992; 6:65-72 [CrossRef][Medline]
6. Barakat LP, Sills R, Labagnara S Management of fatal illness and death in children or their parents. Pediatr Rev 1995; 16:419-424 [Abstract/Free Full Text]
7. Cohen GJ. Bereavement: responsibilities of health professionals. In Chigier E, ed. Grief and Bereavement in Contemporary Society. London, England: Freund Pub House; 1988;2:170-172
8. Green M Helping children and parents deal with grief. Contemp Pediatr 1986; 3:84-98
9. American Academy of Pediatrics, Work Group on Disasters. Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician. Rockville, MD: US Department of Health and Human Services, Center for Mental Health Services; May 1995
10. Koocher GP Talking with children about death. Am J Orthopsychiatry. 1974; 44:404-411 [Medline]
11. Baker JE, Shaffer MD, Wasserman G, Davies M Psychological tasks for bereaved children. Am J Orthopsychiatry. 1992; 62:105-116 [Medline]
12. Mandell F, McClain M Supporting the SIDS family. Pediatrician. 1988; 15:179 [Medline]
13. Hogan NS, Greenfield DB Adolescent sibling bereavement symptomatology in a large community sample. J Adolesc Res. 1991; 6:97-112 [Abstract]
14. American Academy of Pediatrics, Task Force on Coding for Mental Health in Children. The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Elk Grove Village, IL: American Academy of Pediatrics; 1996

	ADDITIONAL READINGS

1. Fanos JH, Nickerson BG Long-term effects of sibling death during adolescence. J Adolesc Res. 1991; 6:70-82 [Abstract]
2. Gudas LJ. Concepts of death and loss in childhood and adolescence: a developmental perspective. In: Saylor CF, ed. Children and Disasters. New York, NY: Plenum Press; 1993:67-84
3. Gudas LS, Koocher GP. Life-threatening and terminal illness in childhood. In: Levine ML, Carey WB, Crocker AC, eds. Developmental-Behavioral Pediatrics. 3rd ed. Philadelphia, PA: WB Saunders Co; 1999:346-356
4. Koocher GP Coping with a death from cancer. J Consult Clin Psychol. 1986; 54:623-631 [CrossRef][Medline]
5. Ptacek JT, Eberhardt TL Breaking bad news: a review of the literature. JAMA. 1996; 276:496-502 [Abstract]
6. Webb NB, ed. Helping Bereaved Children: A Handbook for Practitioners. New York, NY: Guilford Press; 1993
7. Worden JW. Children and Grief. When a Parent Dies. New York, NY: Guilford Press; 1996