Separation and Loss

Separations may be due to temporary causes, such as vacations, parental job restrictions, natural disasters, or parental or sibling illness requiring hospitalization. More long-term separations occur due to divorce, placement in foster care, or adoption, while permanent separation may occur due to 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 Children’s behavior may appear subdued, withdrawn, fussy, or moody, or they may demonstrate resistance to authority.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-aged children may experience impaired cognitive functioning and poor performance in school. Some children may repeatedly ask for the absent parent and question when he or she 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 and wariness that the event will happen again, or the child may feel as if he or she caused the parent’s departure due to magical thinking. If the mother who frequently says “Stop it, or you’ll give me a headache” is hospitalized, the child may feel at fault and guilty. As a result of these feelings, children may seem to be more closely attached to the other present parent than to the absent one, or even to the grandparent or baby sitter 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 re-establish 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 more wary and guarded about re-establishing the relationship with the repeatedly absent parent, and these traits may affect other personal relationships. Parents should be advised not to try to ameliorate 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 USA, about 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 5 yr later, and educational or occupational decline may occur even 10 yr later. It is difficult to sort out all of the confounding factors. Children may suffer when exposed to parental conflict that continues after divorce, and in some cases may escalate. The degree of inter-parental conflict may be the most important factor associated with child morbidity. A continued relationship with the noncustodial parent, as long as there is minimal inter-parental conflict, was a factor associated with more positive outcomes.

School-aged children may respond with evident depression, may seem indifferent, or may be markedly 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 is 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. Outwardly blaming parents may be perceived by a child as fairly risky; parents who discover that a child harbors resentment might punish him or her further for these thoughts or feelings. Children who feel that their misbehavior caused their parents to separate or become divorced have the fantasy that their own trivial or recurrent behavioral patterns caused their parents to become angry with each other. 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 commonly show intense anger. Five years after the breakup, approximately one third of children report intense unhappiness and dissatisfaction with their lives and their reconfigured families, another one third show clear evidence of a satisfactory adjustment, whereas the remaining third 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, and/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 who had experienced it, 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 2 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 2 homes.

The primary care provider may provide an important role for divorcing and divorced parents and their children. When 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 with each other 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 inter-parental conflict, is most beneficial to the child.

Move/Family Relocation

A significant proportion of the population of the USA 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 such changes in family structure 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.

Separation due to Hospitalization

Potential challenges for hospitalized children include coping with separation, adapting to the new hospital environment, adjusting to multiple caregivers, seeing very sick children, and sometimes experiencing the disorientation of intensive care, anesthesia, and surgery. To help mitigate potential problems, a preadmission visit to the hospital is important to allow the child to meet the people who will be offering care and ask questions about what will happen. Parents of children younger than 5-6 yr of age should room with the child if feasible. Older children may also benefit from parents staying with them while in the hospital, depending on the severity of their illness. Creative and active recreational or socialization programs with child life workers, chances to act out feared procedures in play with dolls or mannequins, and liberal visiting hours including visits from siblings are all helpful. Sensitive, sympathetic, and accepting attitudes toward children and parents by the hospital staff are very important. Health care providers need to remember that parents have the best interest of their children at heart and know their children the best. Whenever possible, school assignments and tutoring for the hospitalized children should be available in order to engage the child intellectually and prevent them from falling behind in their scholastic achievements.

The psychologic aspects of illness should be evaluated from the outset, and physicians should act as a model for parents and children by showing interest in a child’s feelings, allowing them a venue for expression, and demonstrating that it is possible and appropriate to communicate discomfort in verbal, symbolic language. Continuity of medical personnel may be reassuring to the child and family.

Parental/Sibling Death

Approximately 5-8% of U.S. children will experience parental death; rates are much higher in other parts of the world more directly affected by war, AIDS, and natural disasters (Chapter 36.2). Anticipated deaths due to chronic illness may place a significant strain on a family, with frequent bouts of illness, hospitalization, disruption of normal home life, absence of the ill parent, and perhaps more responsibilities placed on the child. Additional strains include changes in daily routines, financial pressures, and the need to cope with aggressive treatment options.

Children can and should continue to be involved with the sick parent or sibling, but they need to be prepared for what they will see in the home or hospital setting. The stresses that a child will face include visualizing the physical deterioration of the family member, helplessness, and emotional lability. Forewarning the child that the family member may demonstrate physical changes, such as appearing thinner or losing hair will help the child to adjust. These warnings, combined with simple yet specific explanations of the need for equipment such as a nasogastric tube for nutrition, an oxygen mask, or a ventilator, will help lessen the child’s fear. The primary care provider can be of great help in addressing these issues. Children should be honestly informed of what is happening, in language they can understand, allowing them choices, but with parental involvement in decision-making. They should be encouraged, but not forced to see their ill family member. Parents who are caring for a dying spouse or child may be too emotionally depleted to be able to tend to their healthy child’s needs or to continue regular routines. Children of a dying parent may suffer the loss of security and belief in the world as a safe place, and the surviving parent may be inclined to impose his or her own need for support and comfort onto the child. However, the well parent and caring relatives must keep in mind that children need to be allowed to remain children, with appropriate support and attention. Sudden, unexpected deaths lead to more anxiety and fear, because there was no time for preparation and uncertainty as to explanations.

Grief and Bereavement