Loss, Separation, and Bereavement

Separation and Loss

Separations may be from temporary causes, such as vacations, parental job requirements, natural disasters or civil unrest, or parental or sibling illness requiring hospitalization. More long-term separations occur as a result of divorce, placement in foster care, or immigration, whereas permanent separation may occur because of death. The initial reaction of young children to separation of any duration may involve crying, either of a tantrum-like, protesting type, or of a quieter, sadder type. Children's behavior may appear subdued, withdrawn, fussy, or moody, or they may demonstrate resistance to authority. Specific problems may include poor appetite, behavior issues such as acting against caregiver requests, reluctance to go to bed, sleep problems, or regressive behavior, such as requesting a bottle or bed-wetting. School-age children may experience impaired cognitive functioning and poor performance in school. Some children may repeatedly ask for the absent parent and question when the absent parent will return. The child may go to the window or door or out into the neighborhood to look for the absent parent; a few may even leave home or their place of temporary placement to search for their parents. Other children may not refer to the parental absence at all.

A child's response to reunion may surprise or alarm an unprepared parent. A parent who joyfully returns to the family may be met by wary or cautious children. After a brief interchange of affection, children may seem indifferent to the parent's return. This response may indicate anger at being left or wariness that the event will happen again, or the young child may feel, as a result of magical thinking (see Chapter 24 ), as if the child caused the parent's departure. For example, if the parent who frequently says “Stop it, or you'll give me a headache” is hospitalized, the child may feel at fault and guilty. Because of these feelings, children may seem more closely attached to the present parent than to the absent one, or even to the grandparent or babysitter who cared for them during their parent's absence. Some children, particularly younger ones, may become more clinging and dependent than they were before the separation, while continuing any regressive behavior that occurred during the separation. Such behavior may engage the returned parent more closely and help to reestablish the bond that the child felt was broken. Such reactions are usually transient, and within 1-2 wk, children will have recovered their usual behavior and equilibrium. Recurrent separations may tend to make children wary and guarded about reestablishing the relationship with the repeatedly absent parent, and these traits may affect other personal relationships. Parents should be advised not to try to modify a child's behavior by threatening to leave.

Divorce

More sustained experiences of loss, such as divorce or placement in foster care, can give rise to the same kinds of reactions noted earlier, but they are more intense and possibly more lasting. Currently in the United States, approximately 40% of marriages end in divorce. Divorce has been found to be associated with negative parent functioning, such as parental depression and feelings of incompetence; negative child behavior, such as noncompliance and whining; and negative parent–child interaction, such as inconsistent discipline, decreased communication, and decreased affection. Greater childhood distress is associated with greater parental distress. Continued parental conflict and loss of contact with the noncustodial parent, usually the father, is common.

Two of the most important factors that contribute to morbidity of the children in a divorce include parental psychopathology and disrupted parenting before the separation. The year following the divorce is the period when problems are most apparent; these problems tend to dissipate over the next 2 yr. Depression may be present up to 5 yr later, and educational or occupational decline may occur even 10 yr later. It is difficult to sort out all confounding factors. Children may suffer when exposed to parental conflict that continues after divorce and that in some cases may escalate. The degree of interparental conflict may be the most important factor associated with child morbidity. A continued relationship with the noncustodial parent when there is minimal interparental conflict is associated with more positive outcomes.

School-age children may become depressed, may seem indifferent, or may be extremely angry. Other children appear to deny or avoid the issue, behaviorally or verbally. Most children cling to the hope that the actual placement or separation is not real and only temporary. The child may experience guilt by feeling that the loss, separation, or placement represents rejection and perhaps punishment for misbehavior. Children may protect a parent and assume guilt, believing that their own “badness” caused the parent to depart. Children who feel that their misbehavior caused their parents to separate may have the fantasy that their own trivial or recurrent behavioral patterns caused their parents to become angry at each other. A child might perceive that outwardly blaming parents is emotionally risky; parents who discover that a child harbors resentment might punish the child further for these thoughts or feelings. Some children have behavioral or psychosomatic symptoms and unwittingly adopt a “sick” role as a strategy for reuniting their parents.

In response to divorce of parents and the subsequent separation and loss, older children and adolescents usually show intense anger. Five years after the breakup, approximately 30% of children report intense unhappiness and dissatisfaction with their life and their reconfigured family; another 30% show clear evidence of a satisfactory adjustment; and the remaining children demonstrate a mixed picture, with good achievement in some areas and faltering achievement in others. After 10 yr, approximately 45% do well, but 40% may have academic, social, or emotional problems. As adults, some are reluctant to form intimate relationships, fearful of repeating their parents' experience.

Parental divorce has a moderate long-term negative impact on the adult mental health status of children, even after controlling for changes in economic status and problems before divorce. Good adjustment of children after a divorce is related to ongoing involvement with two psychologically healthy parents who minimize conflict and to the siblings and other relatives who provide a positive support system. Divorcing parents should be encouraged to avoid adversarial processes and to use a trained mediator to resolve disputes if needed. Joint-custody arrangements may reduce ongoing parental conflict, but children in joint custody may feel overburdened by the demands of maintaining a strong presence in two homes.

When the primary care provider is asked about the effects of divorce, parents should be informed that different children may have different reactions, but that the parents' behavior and the way they interact will have a major and long-term effect on the child's adjustment. The continued presence of both parents in the child's life, with minimal interparental conflict, is most beneficial to the child.

Move/Family Relocation

A significant proportion of the U.S. population changes residence each year. The effects of this movement on children and families are frequently overlooked. For children, the move is essentially involuntary and out of their control. When changes in family structure such as divorce or death precipitate moves, children face the stresses created by both the precipitating events and the move itself. Parental sadness surrounding the move may transmit unhappiness to the children. Children who move lose their old friends, the comfort of a familiar bedroom and house, and their ties to school and community. They not only must sever old relationships, but also are faced with developing new ones in new neighborhoods and new schools. Children may enter neighborhoods with different customs and values, and because academic standards and curricula vary among communities, children who have performed well in one school may find themselves struggling in a new one. Frequent moves during the school years are likely to have adverse consequences on social and academic performance.

Migrant children and children who emigrate from other countries present with special circumstances. These children not only need to adjust to a new house, school, and community, but also need to adjust to a new culture and in many cases a new language. Because children have faster language acquisition than adults, they may function as translators for the adults in their families. This powerful position may lead to role reversal and potential conflict within the family. In the evaluation of migrant children and families, it is important to ask about the circumstances of the migration, including legal status, violence or threat of violence, conflict of loyalties, and moral, ethical, and religious differences.

Parents should prepare children well in advance of any move and allow them to express any unhappy feelings or misgivings. Parents should acknowledge their own mixed feelings and agree that they will miss their old home while looking forward to a new one. Visits to the new home in advance are often useful preludes to the actual move. Transient periods of regressive behavior may be noted in preschool children after moving, and these should be understood and accepted. Parents should assist the entry of their children into the new community, and whenever possible, exchanges of letters and visits with old friends should be encouraged.