AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022
Children and Loss: Understanding adverse events in the lives of
children and young people
Judith A. Murray BA (Hons.I) DipEd BEdSt PhD
Senior Lecturer, School of Population Health, The University of Queensland
Summary
Content
Implications for Care
Conclusion
References
Adverse life events and situations such as natural and man-made disaster, educational
failure, social rejection, traumatic loss, family breakdown, abuse, migration and
dislocation, chronic illness and death are not uncommon in the lives of many children and
adolescents. Considerable empirical evidence exists concerning both short- and long-term
deleterious effects of such events on the mental health of children and adolescents. There
is broad acceptance of the need to find means of preventing, or at least reducing,
psychopathology associated with such events or situations. However, those working with
children and adolescents are often overwhelmed by the expectation to provide for the
legitimate needs of an individual child or adolescent while having the daily
responsibility for large groups of children, many of whom are distressed by diverse
adversities. Consequently, a valuable contribution to any program aimed at improving the
mental health of children and young people would be the identification of a common aspect
of adverse situations, the understanding of which could guide carers and educators in the
provision of care for children and adolescents facing diverse life challenges. This paper
presents the concept of loss, and the grief that accompanies loss, as the common element
of many adverse events in the lives of children and adolescents. It presents some of the
core themes developed from an extensive review of the literature that can be used to
integrate the care of children and adolescents facing adverse life events.
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If loss is defined in terms of "being parted from something of value to a person" (Delbridge et al., 1981) it is apparent that most adverse life events involve loss. What is ‘valued’ by the child may be diverse: a person, a relationship, security, perceived future, self-esteem, a place, trust or social functioning. Some losses in the lives of children such as death, accidents, natural disaster, or loss of a pet occur more or less by chance, while others such as weaning, moving from primary to secondary school, or having a friend move away, are part of the developmental changes that occur throughout life (Hockley,1985). Some losses that confront children may be less easily recognized and validated by adults. For example, the loss of expectations and sense of self at being overlooked for a sporting team or a desired peer group (Zakriski, Jacobs and Coie,1997), ‘failing’ a test whatever the child perceives failure to be, or realizing that you are different from other children due to physical illness or intellectual disability (Bluebond-Langner,1996), or family circumstances (Remkus,1991) may not be obvious to others.
Children may also experience loss through being deprived of basic needs, capacities, or safety and security. Children living in situations of poverty, dangerous environments or children who have been neglected, may experience such loss (Garbarino, Kostelny, and Dubrow,1991; Ryan, Kilmer, Cauce, Watanabe and Hoyt, 2000; Tolan, Guerra and Montaini-Klovdahl,1997). Chronically ill children (Bluebond-Langner,1996; Worthington,1989), disabled children (Tyc,1992) or children in institutional care (Eagle,1994) can also experience a sense of loss related to the realization that their childhood is not that as is experienced by their peers. In a similar way, the burden of caring for a physically or mentally ill parent (Beardslee and Podorefsky,1988; Worsham, Compas and Ey,1997), being brought up by an emotionally unresponsive parent (Goodman & Brumley,1990; Weissman, Gammon, John, Merikangas, Warner, Prusoff and Sholomskas, 1987), or having a parent who is incarcerated involve elements of loss for the child, particularly that of the loss of childhood and choice (Downey & Coyne,1990). At times children who suffer such deprivation may not become aware of what they have ‘lost’ until they have had sufficient life experience to recognize their circumstances as deficient (Zupanick, 1994).
There is considerable empirical evidence concerning short- and long-term difficulties associated with a number of adverse events that involve the loss of something of importance to the child or adolescent. For example, adverse effects have been associated with parental death (Worden and Silverman,1996), chronic illness (Cappelli, et al., 1989), parental separation and divorce (Wadsworth, Maclean, Kuh, and Rodgers,1990; Wallerstein,1991; Wolfinger,1998), immigration (Ahearn and Athey,1991), breakdown of a romantic relationship (Kaczmarek and Backlund, 1991), criminal victimization (Pynoos, Steinberg, and Gienjian, 1996) and homelessness (Cohen, MacKenzie and Yates, 1991; Ryan et al., 2000). Of concern also are studies that have identified a link between loss in the lives of young people and suicidal ideation and completion (Kosky, Silburn, and Zubrick, 1990; Marttunen, Aro, and Lönnqvist, 1993; Morano, Cisler, and Lemerond, 1993). However, the general recognition of loss in the lives of children and adolescents has most commonly been restricted to the major identifiable losses of death and family breakdown (AusEinet,1999).
However, clinicians, teachers and families recognize that, while these situations of death and family breakdown are indeed very important, they constitute only a proportion of the adverse events with which children and adolescents are confronted. Slee (1993) investigated the extent of stressful (adverse) events in the lives of non-clinical urban Australian school children aged five to 13 years. In general, children reported experiencing an average of six stressful life events, including a best friend moving away, a change of school, discipline problems at school, the death of a relative, a bad school test result, or parental separation, with 25 percent of children experiencing three to eight serious stressors such as the death of a parent, or hospitalization.
While it would be desirable, it is beyond the resources of the majority of clinicians, schools and communities in general, to have a detailed knowledge of each specific adverse event and be able to implement specific programs of intervention to reduce the mental health problems associated with each. In addition, it is recognized that interventions in mental health need to occur at many different levels from prevention to treatment to maintenance (Mzarek & Haggerty, 1994). To be able to determine a common concept among many adverse life events and design a program of integrated interventions based on such a common concept would provide schools and communities as a whole with a means of rationalizing resources to allow for care to be offered to a much larger group of children and adolescents challenged by various adverse life events.
It is the proposition of this paper that a reinterpretation of adverse life events in
terms of the losses involved in each situation, and the consequent reactions to loss known
collectively as ‘grief’ (Raphael,1984), provides the commonality that can guide
the care of children in many diverse situations. While it is recognized that specific
adverse life events or situations engender unique issues and unique losses, this paper
proposes that there exist some common aspects of loss in general, and among children and
adolescents in particular, that can be identified. Knowledge of these commonalities can
enhance the understanding of loss in general and thereby increase the likelihood that
appropriate early intervention can be provided. The remainder of this paper will present a
set of themes for understanding adverse life events in the lives of children and
adolescents considered from the perspective of loss. A substantial literature review of
adverse events and wide community consultation results in nine summative, easily
understood and communicable statements of which eight are presented here.
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- Grieving is a normal process.
Raphael (1984) defines grief as the reaction to loss, and mourning or grieving as the psychological process whereby a person undoes the bonds that bound him or her to the thing that was lost. Consequently, grieving is a healing process that allows a person to progress from a state of significant disorganization at the realization of the loss of the previous life situation, to a position of being able to reinvest in life. There exist many schools of thought concerning the process of grieving.
Debate concerning the process of grieving within these various schools of thought has not only been concerned with the manner in which children grieve. There has been a more fundamental debate concerning whether or not children grieve at all (Deutsch,1937; Freud,1960; Wolfenstein,1966; Bowlby, 1961; Furman,1964; Kliman,1968).
Baker, Sedney and Gross (1992) proposed that children accomplished certain tasks at different phases in their mourning. In comparison to adults, two aspects of mourning appear to have particular significance in the grieving of children; the need for the child to feel safe in a secure environment in the early phase of loss, and the need for the child to be able to maintain a durable internal relationship to the lost love object over time. Balk (1996) presented evidence in support of three alternate models of adolescent grieving: linking of grief to developmental tasks, the presentation of adaptive tasks and coping skills, and a model of sentiments essential for human wholeness.
- The experience of loss is ‘integrated’ into the basic psychological
functioning of the person, even from the earliest age. Therefore there exists the
potential for personal growth and personal deterioration.
Although not necessarily the intent of theorists concerned with trying to describe the process of grieving a loss, there has been a tendency to suggest that the final phase of the grief process, often referred to as resolution, represents an end point in the process of mourning. However, there is considerable debate concerning the inevitability of the resolution of grief (Stroebe, Van der Bout and Schut,1994). Life experiences including losses are now becoming interpreted more in terms of a salient, but evolving, underlying personal life structure commonly known as the life story (Cohler,1991). If loss is integrated into the existing life narrative of children, there are two possible outcomes: growth and deterioration (Tedeshi, Park and Calhoun,1998). For example, Schaefer and Moos (1992) argue that over the life span there is a positive role played by life crises in the development of adaptive coping responses. However, as discussed previously, long-term maladjustment may also be a consequence of loss.
- Dealing with loss is a very individual, mostly private, and even at times, lonely
experience.
Many factors will affect the severity of children’s individual reactions to loss: factors related to the individual child, factors related to the particular situation of loss, and factors external to the child. Intellectual, physical and moral developmental changes are particularly influential in determining children’s interpretations of the loss and their consequent reactions and adaptation to loss (Dyregrov,1991; Thomas,1996). In addition to individual development, differences in children’s attributional style (Hegar,1989), coping styles and strategies (Mantzicopoulos,1990; Rotheram-Borus, Trautman, Dopkins, and Shrout, 1990), mental capacity, gender (Dyregrov,1991), personality / temperament (Thomas & Chess,1977) and previous life experiences will moderate children’s reactions to loss.
Particular characteristics of the loss can also influence a child’s or adolescent’s reaction to loss: loss of something or someone central to the security of the world of the child or adolescent, chronicity, suddenness, or the involvement of trauma (Bluebond-Langner,1996; Cappelli et al., 1989; Doka,1996; Tyc,1992).
In terms of external factors affecting children’s individual reactions to loss, the handling of the situation by significant others in the life of the child is particularly important (Dyregrov,1991; Schwab,1997; Worden and Silverman,1996) as is the broader societal context of loss (Fuller,1998; Sam,2000; Shimabukuro, Daniels and D’Andrea,1999).
- Losses rarely exist alone.
While a presenting or primary loss may have greatest significance to the child, associated or secondary losses may influence the ability of the child to adapt to the primary loss.
- A child or adolescent experiencing loss remains a child.
More so than adults, children may express their grief by behaving in ways that are not easily interpretable as reactions to loss (Dyregrov,1991; McKissock,1998). Consequently, it can be difficult, particularly in the long-term, to differentiate between children’s and adolescent’s grief reactions, and behaviors associated with normal development.
- Children are not illogical. They are just limited by their experience.
Children often apply incorrect, yet logical, reasoning to their understandings of a situation of loss (Brent,1977-78). Consequently, in caring for children affected by loss, it is vital to determine the logical links in the thought process that the child employs in understanding the loss, rather than assuming adult reasoning.
- It is a privilege to be invited into the experience of loss of a child or adolescent.
Recognizing that one must be invited into a child’s loss by the child him or herself encourages a) children’s ownership of the mourning process, b) a respect for other carers involved in the child’s loss who may also gain an invitation, c) an understanding of children’s approaches for help, and d) an acceptance of a child’s distrust of outside help.
- Loss threatens our sense of safety, mastery and control. For a child or adolescent in
an adult’s world, the loss of a sense of safety may be even more pronounced.
This assumptive world (Parkes,1971) of the child develops over time as his or her world increases in size to include other people and places outside home and family (Raphael,1993). Loss often robs children of the confidence that they can accurately predict the world by relying on the assumptions they hold. This loss of innocence and confidence in the predictability of the world can interfere with a child’s ability to make decisions, or to trust his or her own reactions and those of others (Janoff-Bulman and Frantz,1997). It may also lead to children trying to control any aspects of their world over which they feel some influence.
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In interpreting adverse events in the life and children and adolescents from a loss perspective, overall principles of care begin to emerge that can direct general and specific interventions. There is insufficient space in this paper to address them in detail. However, in general, the care of children and adolescents affected by loss will involve: a) respecting the totality of the world as it is perceived by the child or adolescent, b) gaining an understanding of that world and the manner in which the loss has disrupted the security of that world, and c) enabling or empowering children to regain some sense of safety or control over the fear and emotional pain that accompanies such upheaval. This essential aspect of returning ‘safety’ to the world of child affected by loss can guide a whole-of-school and whole-of-community approach to care. Schools and carers can best determine the means by which they help return safety to world of children in their care, thereby ensuring local solutions to local problems. Safety measures may include maintaining a routine that provides continuity among great change, training staff to recognize grief reactions, acknowledging and validating the loss, improving the ability of other students to offer support, providing activities and opportunities over which children can feel a sense of mastery, spreading a protective umbrella from home to school to community, having the place and personnel to provide group and individual support, and teaching children effective coping strategies.
Considerable empirical evidence exists with respect to the deleterious outcomes that
can be associated with many adverse life events that confront children and adolescents.
The literature concerning the prevention of psychopathology places considerable emphasis
on preventive and early intervention (Mzarek & Haggerty,1994) including intervening
during times of adversity. Such intervention requires that those who care for children and
adolescents on a regular basis such as parents, teachers, medical personnel, mental health
professionals, day care and youth workers are assisted to recognize emerging problems and
avert ongoing difficulties through early intervention or referral to appropriate services.
This paper proposes that the recognition that many adverse life events with which children
or adolescents are confronted involve loss, and having an understanding of loss in
general, will assist practitioners to care for children in these many diverse situations
by forming a foundation for guiding the development of interventions of a universal nature
and more specific programs for particular adverse life events.
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