I was about to begin a collaborative practice with a very talented physician when he died in a tragic accident. He left behind many grateful patients and heartbroken colleagues. He also left behind 5-year-old twins whose lives are forever changed. I have hugged my own children a little tighter since his death, and I think about his son and daughter often.
As a PA, do you feel prepared to help young children after such devastating trauma? I asked one of my favorite colleagues, Dr. Lloyd “Chip” Taylor, a talented clinical psychologist with expertise in caring for children and families in similar situations, for his advice. Here is what he shared.
The death of a parent is one of the most difficult events a child might face. It prematurely exposes the child to the unpredictability of life and the tenuous nature of daily existence. As recently as two generations ago, death and dying were common enough that children experienced them routinely.1 This exposure reduced the impact and normalized the grieving process. Death is much less common now, however, and as a result it is more traumatic to children and adults alike. We are especially not accustomed to the death of a parent of young children.
When working with a child who has lost a parent, PAs must consider developmental factors that influence how the child responds to the event.2 Toddlers cannot understand death and dying, and while they may cry and demonstrate affective deregulation, these expressions of emotion are likely the result of watching adults' grief and mirroring those behaviors.1 Changes in the routines and structure of the home will affect how well the child adjusts to the loss of a parent. The most important thing PAs can do is to emphasize the importance of consistency among chaos. Consistency in interactions and routines provides the child with a sense of stability, and caregivers should be encouraged to recognize this. If order is not maintained, children will evidence adjustment difficulties—not directly as a result of the loss but due to the environmental changes resulting from that loss. Caregivers also must recognize the impact of their own mourning on their ability to parent consistently. If grieving makes it difficult for the remaining parent or caregiver to engage with the child, others should be encouraged to step in. Consistency across routines and environments is essential, especially for younger children.
Preschool children view death as a temporary, reversible condition. They have experienced times when loved ones have gone away, only to later return.1 These prior experiences provide evidence to support the child's notion that mom or dad will return from death. The finality of death and the chronicity of subsequent mental health concerns are not components of the preschool child's cognitive schemas. The child may ask when the dead loved one will return and also may engage in behaviors, such as preparing for the dead parent's return, which look odd but make perfect sense from a developmental perspective.
Children will respond emotionally to the loss of a parent, frequently crying or becoming disruptive. Symptoms of depression routinely manifest as disruptive behavior in children. Externalizing behaviors such as outbursts and aggression are common manifestations of depression among children and are likely to be the result of the child sensing that something is wrong in the environment. These behaviors are not necessarily permanent and frequently will resolve as the child's world adjusts to the loss. Changes in routines can also lead to anxiety and depression in children. Understanding the source of these behaviors will be helpful as you work with parents and children dealing with loss. This is a time to be cautious with diagnosis and to view behaviors in light of the ongoing changes the child is experiencing rather than as manifestation of a behavioral disorder.
The grieving process is repeated across every successive developmental hurdle.1 As the child becomes a young adult, the permanency of death and the ongoing “losses” will take on new meaning in light of the social demands facing that child. The death of a parent is not an event but a process a child goes through uniquely, and repeatedly, at each stage of development.
PAs are intimately involved with the best and worst moments in our patients' lives. They trust us to have answers when they do not or when hope is lost. If I have learned anything from my professional interactions with children suffering from mental illness and loss, it is that the atypical is typical. As Chip describes, we can demystify these symptoms or behaviors and help a remaining parent or caregiver understand why they are occurring. PAs are ideally situated to intervene in situations of parental loss. We can do much to help these children, such as providing practical strategies that help create environments that support healing and normal development. If you have not done so already, I encourage you to develop a relationship with a licensed counselor or psychologist in your own community when a team approach makes sense.
1. Willis C. The grieving process in children: strategies for understanding, educating, and reconciling children's perceptions of death. Early Childhood Education Journal.
2. Costa L, Holliday D. Helping children cope with the death of a parent. Elementary School Guidance and Counseling.