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Children and young people often report feeling alone and different following the death of someone important in their lives. While no routine data are collected in the UK on this group, estimates suggest that, in fact, the majority of young people face the death of a close relative or friend by the time they are 16 years old.1 Five per cent of young people have been bereaved of a parent by this age.2 Around 1 in 29 school-aged children have been bereaved of a parent or sibling and 1 in 16 have experienced the death of a friend.3
Background characteristics of bereaved children
Varying mortality patterns by social class and geography affect the risk of bereavement.1 At birth, children who go on to be bereaved of a parent are less likely than their peers to have parents with some experience of extended education or a father in a professional or managerial occupation, and more likely to have a father not in work.2 Higher levels of disadvantage persist: greater proportions of children bereaved of a parent or sibling live in economically inactive or low-earning households than their peers.3 These children are also more likely to have experienced other stressful events including a parent having a physical illness, serious mental illness or financial crisis and the child spending time in public care. These additional difficulties may precede or follow the death; some are linked to it while others are independent.3
The impact of bereavement in childhood
Common children's grief reactions in-clude sadness and crying, anxiety (including about their own or others' safety), guilt, anger and acting out, physical difficulties including somatic symptoms, illness and accidents, problems at school, sleeping difficulties, and vivid memories.4 While many grief reactions abate, others can persist or emerge. By 2 years after the death of a parent, children's self-esteem and beliefs about their control over life are significantly lower than their non-bereaved peers, and the difference in levels of clinical difficulty between these groups is significant.4
A comprehensive literature review (largely studies on the death of a parent) highlighted the significant effects of bereavement on a range of life issues, including depression (in the short term or in adulthood), criminal or disruptive behaviours, early sexual activity, educational attainment and employment status, leaving home early and self-concept and self-esteem.1 The death of a parent by the age of 16 is associated with lower employment rates at the age of 30.2 For women, it is also associated with being a smoker, having depressive symptoms and failing to get any sort of qualification.2 Not all the changes that bereavement brings are negative: some parentally bereaved young people report growth in areas such as a more positive outlook, gratitude, appreciation of life, living life to the full and altruism.5
The evidence on children's bereavement outcomes is difficult to summarise and some findings contradict others.1 In part, this is because children experience bereavement in a wide range of circumstances and opposite effects can cancel each other out in large scale quantitative studies.1 An 8-year-old child whose lone parent dies suddenly and who enters foster care will have a different experience from a 15-year-old child whose parent's death is expected but who is being bullied at school. As shown, some children are more likely to experience bereavement; additionally, significant bereavement seems to bring greater risks to those who are already disadvantaged or have faced multiple losses.1
While a death of someone significant is a profound event in itself, it often brings other changes, such as new roles within the family, moving house or a drop in family income. Bereavement involves adjusting to these changes—and often to the grief reactions of others in the family—as well as to the loss of the person. The accumulation of further stressful events is associated with children's emotional and behavioural difficulties.4
The journey of bereavement takes place alongside children's journey of development. They often revisit or re-experience their grief in new ways as they make further transitions, as the meaning of the death and their changed relationship with the person who has died takes on new significance.4
Many cumulative, interrelating risk and protective factors mediate or moderate children's experiences.1 4 These can be at the level of the child (such as their prior experiences of loss, their preferred coping style), their family and social relationships (including their prior and ongoing relationship with the person who has died), their wider environment and culture, and the circumstances of the death (including whether the child perceives this as traumatic).1 4
The availability of support
The family is a key context for bereaved children and young people. Children's outcomes correlate strongly with their surviving parent's mental health, coping style, levels of warmth and discipline, and communication.1 4 6
After following 125 parentally bereaved children and their controls for 2 years, Worden identified that children need adequate information, their fears and anxieties to be addressed, reassurance that they are not to blame, careful listening, validation of their feelings, help with overwhelming feelings, involvement and inclusion, continued routine activities, modelled grief behaviours and opportunities to remember.4
Ideally, these needs are met in a stable and supportive family. Yet while parents are grieving themselves, it can be a huge strain to continue routines and remain emotionally and practically available to their children. Following the death of a partner, they will be adjusting to new responsibilities of life as a single parent:4 the death of a child poses different challenges. Beyond the family, in school and other contexts, adults and peers may be uncertain about how to help or may be worried about making things worse. Many children report having no one to talk to.1
An organised response
Reviews suggest the need for a range of proactive and reactive interventions to meet the differing needs of children and their families over time.1 6 A number of services offering such interventions exist in the UK.7 Typically, they offer a range of services (see figure 1)8 across a particular catchment area, aiming to modify risk and protective factors and adaptation processes, such as improving family communication or children's coping skills. While some are offered to particular groups (eg, the children of patients at a particular hospice), others work with all children, whatever the cause of death, be it anticipated, sudden, violent or traumatic. Many offer additional services such as training to help professionals already known to children support them in their bereavement.7
The provision is patchy: 31% of local areas lack a service which covers the whole area and works across all causes of death.9 Even where services exist, they would often not be able to see all the children who might benefit from or want their support.1 Eighty-five percent of services are based in the voluntary sector7 and funding is often precarious. Recent cuts to public services have resulted in the closure of some services.10
The impact of interventions
Children and young people have reported a range of benefits from organised services including feeling relieved and less isolated through meeting others and being able to talk to someone outside the situation, understanding more and feeling less anxious. Parents reported finding it helpful to be with others. They felt less alone, helped with their own pain and grief, supported and reassured in parenting their child, more confident and more able to communicate openly in their families.11
Despite strong evidence of participants' satisfaction, meta-analyses of the effectiveness of interventions have found small to moderate effect sizes with greater effect sizes for those targeted at children showing most difficulties.12 13 This may be because inappropriate tools are being used to measure change, such as those validated for populations showing general clinical difficulties. As not all children will reach these thresholds, the sample as a whole is less likely to show change. Using these tools may pathologise children's grief12 and fail to capture more subtle experiences and aspects of service use.14 Few studies have followed participants over long periods, although emerging evidence from one intervention suggests that its positive impact on mental health and self-esteem grows over 6 years. At this point, a wider group of children demonstrate benefits, not just those who faced greater difficulties at programme entry.15
Developing appropriate tools linked to the specific aims of interventions could allow evidence of their differing benefits to emerge13 and is a priority for the sector.14 More work is also needed to follow children—bereaved of a range of relationships—over longer periods, to learn more about the course of their grief and determine appropriate ways of supporting them and their families to adjust to a new life.1 14 15 Without robust evaluation data to support the case for childhood bereavement services, inequalities in access to provision will persist or worsen and children will continue to feel alone in their grief.
Funding This editorial received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests AA-G, AP and SR are respectively the Patron (unpaid), Coordinator (paid) and Chair (unpaid) of the Childhood Bereavement Network www.childhoodbereavementnetwork.org.uk.
Provenance and peer review Not commissioned; externally peer reviewed.