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Supporting the Grieving Child and Family David J CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Supporting the Grieving Child and Family David J. Schonfeld, MD, FAAP, Thomas Demaria, PhD, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, DISASTER PREPAREDNESS ADVISORY COUNCIL The death of someone close to a child often has a profound and lifelong abstract effect on the child and results in a range of both short- and long-term reactions. Pediatricians, within a patient-centered medical home, are in an excellent position to provide anticipatory guidance to caregivers and This document is copyrighted and is property of the American to offer assistance and support to children and families who are grieving. Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy This clinical report offers practical suggestions on how to talk with of Pediatrics. Any confl icts have been resolved through a process grieving children to help them better understand what has happened and approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial its implications and to address any misinformation, misinterpretations, involvement in the development of the content of this publication. or misconceptions. An understanding of guilt, shame, and other common Clinical reports from the American Academy of Pediatrics benefi t from reactions, as well an appreciation of the role of secondary losses and expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of the unique challenges facing children in communities characterized by Pediatrics may not refl ect the views of the liaisons or the organizations chronic trauma and cumulative loss, will help the pediatrician to address or government agencies that they represent. factors that may impair grieving and children’s adjustment and to identify The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking complicated mourning and situations when professional counseling is into account individual circumstances, may be appropriate. indicated. Advice on how to support children’s participation in funerals All clinical reports from the American Academy of Pediatrics and other memorial services and to anticipate and address grief triggers automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time. and anniversary reactions is provided so that pediatricians are in a better DOI: 10.1542/peds.2016-2147 position to advise caregivers and to offer consultation to schools, early education and child care facilities, and other child congregate care sites. Accepted for publication Jun 27, 2016 Pediatricians often enter their profession out of a profound desire to PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). minimize the suffering of children and may fi nd it personally challenging Copyright © 2016 by the American Academy of Pediatrics when they fi nd themselves in situations in which they are asked to bear FINANCIAL DISCLOSURE: The authors have indicated they do witness to the distress of children who are acutely grieving. The importance not have a fi nancial relationship relevant to this article to of professional preparation and self-care is therefore emphasized, and disclose. resources are recommended. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose. INTRODUCTION At some point in their childhood, the vast majority of children will To cite: Schonfeld DJ, Demaria T, AAP COMMITTEE ON experience the death of a close family member or friend 1, 2; approximately PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, 1 in 20 children in the United States experiences the death of a parent DISASTER PREPAREDNESS ADVISORY COUNCIL. Supporting the Grieving Child and Family. Pediatrics. 2016;138(3):e20162147 by the age of 16. 3 Despite the high prevalence of bereavement among Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 :e 20162147 FROM THE AMERICAN ACADEMY OF PEDIATRICS children, many pediatricians are introduced some of the key issues that surviving adults may not have uncomfortable talking with and that pediatricians should consider yet appreciated (eg, “I don’t know if supporting grieving children. 4 in providing support to grieving I ever will feel comfortable having 7 Bereavement is a normative children. Guidance is available my own children when I grow up, experience that is universal in nature, elsewhere regarding how to support without Mom there to help me.”). but this does not minimize the impact families faced with the impending When children ask such questions or 4, 8 of a loss. The death of someone close or recent death of their child, make similar comments, surviving to a child often has a profound and including practical advice on how family members may become lifelong effect on the child and may to approach notification of parents tearful and/or obviously upset. result in a range of both short- and about the death of their child in a Children may misinterpret these 8, 9 long-term reactions. Pediatricians, hospital setting or in the unique expressions of grief triggered by 10 within a patient-centered medical context of a disaster. Because their questions as evidence that the home, are in an excellent position traumatic events often involve loss, questions themselves were hurtful to provide anticipatory guidance to complementary information on or inappropriate. They subsequently caregivers before, during, and after providing psychosocial support in the may remain silent and grieve alone, a loss and can provide assistance aftermath of a crisis can be found in a without support. In addition, when 11 and support in a number of areas, recent clinical report, which may be children lose a parent or other close including the following: particularly relevant to pediatricians family member, they are often fearful providing care in emergency that others they count on for support • exploring and confirming that departments and intensive care may also die and leave them all alone. children understand what has settings. Children may find it particularly occurred and what death means; unsettling to observe their surviving • helping to identify reactions such caregivers struggling and often as guilt, fear, worry, or depressive IDENTIFYING CHILDREN’S LOSS respond to their surviving parent(s) symptoms that suggest the need EXPERIENCES demonstrations of grief by offering for further discussion or services; support or assistance (eg, “Don’t In a busy pediatric practice, it is likely worry Daddy, I can help do many of • providing reassurance to children that a pediatrician interacts with a the things Mommy used to do; we who become concerned about child who is grieving a death virtually are going to be okay.”), rather than their own health or those of family every week, if not every day. But asking for help themselves, which members; many children who are grieving show may convince surviving caregiver(s) • few outward signs during an office offering support to grieving that the child is coping and has no visit. From an early age, children children and their families to need for assistance. For this reason, learn that questions or discussion minimize their distress and it is important for pediatricians to about death make many adults accelerate their adjustment; offer to speak with children privately uncomfortable; they learn not to talk • informing families about local after a family death to identify about death in public. In the context resources that can provide their understanding, concerns, and of a recent death, children may additional assistance; and reactions without children feeling also be reluctant to further burden that they need to protect surviving • offering advice on funeral grieving family members with their caregivers. attendance of children. own concerns. Pediatricians also can play an Children’s questions about the Caregivers who are struggling with important role in supporting impact of a personal loss can be their own personal grief may be parents and other caregivers after quite poignant and/or frame the particularly reluctant, or even unable, the death of a child, even in the experience in concrete and direct to recognize or accept their children’s 4–6 absence of surviving siblings. In terms that underscore the immediacy grief. The reality is that many addition, children may experience and reality of the loss to adults children in this situation are grieving grief in response to a range of other (eg, “If Mommy died, does that alone, postponing expressing their losses, such as separation from mean that she won’t be here even grief until a time when it feels safer, parents because of deployment, for my birthday? How can I live or seeking support elsewhere, such incarceration, or divorce, which the rest of my life without her?”). as at school or after-school programs may be helped by similar caring Adolescents who are in a better where they can talk about their strategies. position to appreciate the secondary feelings and concerns with adults This clinical report is a revision losses and other implications of a who have personal distance from the of an earlier clinical report that significant loss may raise concerns loss.
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