Grief, Loss, and Coping With Change

Barbara Pisick MED, RN, CS

INTRODUCTION

The cycle of birth, life, and death is ongoing and ever changing. Buddhist philosophy, which emphasizes rebirth and evolution of the soul over time, exemplifies the process of transformation. The death of old ideas that no longer serve current purposes gives birth to new concepts and technologies that alter the process of living. Often, fearful people respond to new information with a more rigid defense of their old beliefs. The ability to cope effectively with change, however, is a critical component of successful living.

This chapter discusses grief, loss, and change from a developmental perspective. It provides content meant to assist primary care providers in identifying children who are struggling with these basic life concepts. It also presents intervention strategies for such children.

CHANGE IN FAMILIES

Change in families occurs through new experiences as different family members grow, marry, have children, age, and die. These experiences continuously transform the family system. The role of parents is to help children develop age-appropriate coping skills and to assist with the process of change as children gain independence.

Primary care providers have a unique opportunity to assess and target interventions for at-risk children. Clinicians can provide an environment for helping to transform dysfunctional communication patterns within the family, in addition to teaching parenting and coping skills. Parents who are unable to help and nurture their children appropriately often lack such abilities not because of disinterest, but because their own parents lacked such skills. Every parent’s style of childrearing reflects his or her own experiences of being parented. Providers must perform all interventions without judgment to enhance relationships among all family members. Providers can be role models for clear communication, teaching children how to be accepted, respected, and understood.

Influence of Birth Order Position

Birth order position is a significant variable that influences a child’s growth and development. The way a child views the world usually is established by age 6 years. Children’s perceptions of the world tend to serve as a filter for them throughout life. Awareness of a child’s perceptions is essential to understanding the factors that motivate him or her.

The first-born child usually provides parents with their first parental experience. Parents often give this child some measure of power over younger siblings. The trauma of dethronement usually occurs for the first-born child at the birth of the second child. The intensity of that experience depends on the number of years between the two siblings and other variables. Parents can help older children accept new siblings by giving all family members sufficient attention and affection.

Clinicians may be able to understand parents better by considering the framework of the parents’ experience as well. Often parents treat children differently according to their own birth order placement and childhood relationships with siblings.

Loss Through Moving

When families move frequently, children lose connections with their schools and communities. The disruption they experience with a move heightens the loss of friends and familiarity. During this process, children may have difficulty making new friends and, consequently, feel isolated. Parents should consider the child’s level of psychosocial development and the concurrent adjustment to the new situation to respond appropriately to their child’s behavior. From ages 10 to 12 years, girls value intimacy and exclusiveness in friendships. They usually play in small groups. Boys generally play in large groups, and recreation often involves sports. As both groups move into adolescence, cliques and friends become extremely important.

Parents need to follow through with children after a move, exploring whether children are adjusting to the new school and environment. Parents must actively pursue information. Children may feel shame, guilt, and discomfort when entering a new social milieu. Developing new friendships can be quite difficult if a child is shy or if groups and cliques at the new school already are established. Many children suffer in silence rather than face humiliation. Table 27-1 provides developmentally appropriate suggestions for parents to help children deal with the loss of beloved friends or pets through moving.

Loss Through Divorce

Approximately 1.25 million children live in divorced families. When families divorce, many children feel like they are losing one parent. They may have to share parents because of remarriage and blending of families. Children of divorce often feel left out and isolated. Children experiencing parental divorce find it very stressful. They may feel emotionally distraught, afraid, guilty, and angry. These feelings can disrupt school performance and peer relationships.

Children younger than 3 years usually demonstrate regressive behavior. Children between ages 3 and 6 years can experience a more concrete realization of the meaning of divorce, which may be manifested through shock and depression. Children ages 4 to 6 years often use fantasy and self-blame as a way of coping with their stress. They may regress, withdraw, and have tantrums. Through the normal developmental process, the school environment often serves as an alternative “home,” dedicated to children’s development and social well-being. School-age children coping with parental divorce often experience somatic symptoms and
deteriorating school performance. Peer relationships may suffer, and children may isolate themselves from peers and adults. Adolescents are often very aware of difficulty between their parents. They may look to other family members and peers for support. They may side with one or the other parent.

Long-term effects of divorce depend on the child’s age when it happens. Usually young children and adolescents have the best outcomes, while preadolescent children in middle school suffer the worst long-term effects. The findings of a 15-year study of 100 children from divorced families found children had the best outcomes when they had contact with both parents and were able to maintain their relationships (Wallerstein & Blakeslee, 1989).

Children of any age who have good relationships with parents and can talk about the effects of divorce will handle the situation more effectively. Providers can help families address post-divorce issues by helping them identify parenting resources, values, and visitation arrangements. Table 27-2 highlights developmentally appropriate interventions for providers to use to help patients whose parents are divorcing.

Loss Through Other Circumstances

Children are at tremendous risk if they grow up in abusive homes, including those with alcohol, drug, sexual, or physical abuse; live in homes where parents are teenagers or the family experiences poverty; or attend schools in which violence occurs. Children in these circumstances usually do not complain. They may either withdraw out of fear or act out their aggression.

Loss Through Abuse

Families coping with substance addiction are found at all socioeconomic levels. These families often experience role confusion, with the oldest children being forced into a parental role. Arguments, illogical thinking, and denial are paramount characteristics of these families. Children are often fearful when parents are out of control. In these families, children do not learn the healthy coping skills they need for adaptation in society. These youngsters are often withdrawn, aggressive, angry, and anxious. They experience developmental problems and difficulties discerning between fantasy and reality.

Early childhood neglect or abuse causes anxiety and insecure attachment in children. These children may become severely upset when separated from their parents, which can lead to subsequent problems in forming and maintaining intimate relationships (Schneider-Rosen & Cicchetti, 1984). Beck (1976) asserts that parental abuse is an antecedent to depression. Adult women whose parents were addicted to alcohol score high for depression (Benson & Heller, 1987). Depression is common in adults and adolescents who were molested as children (Browne & Finkelhor, 1986; Jehu, Gazan, & Klassen, 1984–1985).

Many adults who abuse children are themselves victims of childhood abuse, demonstrating multigenerational patterns of abuse. Chapter 22, Chapter 23, and Chapter 28 offer content that can give the reader further insight into the causes and consequences of childhood abuse.

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