By Diana Mahoney, New England Bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com
“So many feelings and so much pain
Your death really hurt me; I'll never be the same
I try to express it, try to explain
So many feelings and so much pain.”
These lyrics by Thomas A. Dalton, a West Palm Beach, Fla.-based music therapist and licensed mental health counselor, give voice to the inner turmoil that many grieving adolescents feel but cannot speak.
The death of a parent, sibling, other family member, or friend can be devastating. To adolescents, the magnitude of such a loss may be exacerbated because it inevitably disrupts the normal trajectory of adolescent development.
In his seminal model of psychosocial development, Erik H. Erikson identified adolescence as a milestone of personality formation, defined primarily by the conflicting extremes of integration and separation. According to his theory, adolescents are struggling to belong and to be accepted, but they also are struggling to become individuals. Successful passage through this developmental stage requires a delicate balance (“Childhood and Society” New York: Norton, 1950).
The loss of a loved one can wreak havoc on these struggles, both by rendering the teen “different” from his peers when he longs to be one of the crowd and by inducing a heightened sense of vulnerability that can disrupt the teen's burgeoning sense of independence The adolescent might be torn between needing family support but wanting to be independent, as E.B. Weller, R.A. Weller, and J.J. Pugh wrote in the chapter titled Grief in “Child and Adolescent Psychiatry: A Comprehensive Textbook” 2nd ed. (Baltimore: Lippincott Williams & Wilkins, 1996).
The stages of grief are fairly well defined in adults, but the bereavement process in adolescents is murky. Bereaved adolescents are faced with the challenge of coping “behaviorally, cognitively, and affectively” with certain core issues as their development proceeds from one level to the next, according to ego-development research by Stephen Fleming, Ph.D, and Reba Adolph, Ph.D., which often means reliving and readapting to their loss at each developmental phase (“Adolescence and Death” New York: Springer, 1986).
The impact of grief on these issues can be seen in the findings of the Harvard Child Bereavement Study, initiated in 1987 by J. William Worden, Ph.D., and Phyllis Silverman, Ph.D. The study examined the impact of a parent's death on children and adolescents aged 6–17 by interviewing 125 children who had experienced parental loss and their surviving parent at 4 months after the death, as well as 1 and 2 years later.
Compared with their nonbereaved peers, bereaved adolescents in the study were more fearful and anxious, considered themselves academically and behaviorally inferior, had more trouble getting along with peers and struggled with a sense of belonging. The findings persisted over time, with the grieving teens exhibiting more withdrawn behavior, as well as more anxiety, depression, and social problems as assessed on the Child Behavior checklist (“Children and Grief: When a Parent Dies” New York: Guilford, 1996).
Chief among the factors that influenced the course and outcome of the adolescents' adjustment to loss in the Harvard study was how the surviving parent responded to the death. Participants were at increased risk for emotional and behavioral problems if they had experienced multiple family stressors and changes, if the surviving parent had experienced depression or other health problems, or if the surviving parent had ineffective coping skills.
Similar findings were reported more recently by Julie Cerel, Ph.D., of the University of Kentucky, Lexington, and her colleagues. The investigators interviewed 360 parent-bereaved children between the ages of 6 and 17 and their surviving parents four times during the first 2 years after the death and compared psychiatric symptoms among the bereaved children with those of community control children and their parents.
The investigators also compared the symptoms of children and adolescents with simple bereavement (no significant other stressors) to those of complex bereaved children with an average of 1.7 additional stressors, such as another death or serious illness in the extended family (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:681-90).
Compared with community controls, bereaved children and adolescents experienced significantly more psychiatric problems in the first 2 years after death, particularly among youth of depressed parents and those from families of lower socioeconomic status, the authors reported. The findings provide compelling evidence in favor of preventive efforts that include screening bereaved children and teens for such risk factors as depressive symptoms in the surviving parent, additional family stressors, and lower socioeconomic status to identify those youth who might require more careful monitoring and whose parents might be in need of support, the authors wrote.