The effects of parental bereavement in childhood

The aim of this study is to present a general overview of the evidence base in relation to the effects of parental bereavement in childhood. The primary focus is upon research conducted during the past ten years, the available commentary and key theoretical ideas on the topic, notably from Bowlby (1969; 1980), Parkes (1986) and Worden (2003) together with an outline of the contemporary information and guidelines available for those directly involved with this phenomenon, particularly parents and children. An overview of the research suggests that there areconflicting findings, particularly in terms of the nature and extent ofpsychological difficulties, such as depression, that may present inlater life. Two clear messages seem to emerge. Firstly, a significantnumber of studies indicate that further research is needed into theinfluence of variables that potentially mediate, or facilitate, theoutcome for the bereaved child, such as the childs personality traits,family and school factors and other life events. Secondly, thereseems to be a need for more longitudinal studies in this area andstudies which ask similar questions and adopt similar research designand methodology, particularly in the qualitative field, so that usefulcomparisons may be made between different findings. Chapter One Introduction The purpose of this literature review is to explore the evidence basein relation to the effects of parental bereavement in childhood. Theresearch and commentary on this topic is useful in terms of social workpractice because it offers much insight into the experiences and needsof children who have lost a parent. Furthermore, the evidence includesmuch background theoretical material regarding issues of attachment,loss, grief and the making and breaking of affectional bonds forchildren, offering useful insights for those working with children inneed. The death of a parent in childhood, by definition, is oftenpremature and unexpected. It is an event commonly understood tointerfere with the normal process of growing up. As the research andcommentary in this field demonstrates, the childs life is shaken fromits very foundations and the confidence the child has developed thusfar in the world around them and within themselves has effectively beendestroyed (Brown, 1999). This review offers a general overview of thecurrent literature relating to parental death in childhood to include arange of research studies undertaken within the last ten years,commentary by theorists and writers on the topic such as Bowlby (1969;1980) and Parkes (1986) underpinning much of the research and aselection of the advice, information and guidelines available onchildhood bereavement and offered to interested parties such asparents, service providers and the children themselves. This review differs from other reviews on the topic. Firstly, itconstitutes the most recent review of its kind, the latest review beingthat undertaken by Dowdney (2000), at least as far as can be determinedgiven the limitations on time available to search for such reviews.Secondly, this review includes an up-to-date indication of thepractical and accessible guidance and information available tointerested parties on child bereavement which is not present in otherreviews, such as that by Dowdney (2000). The choice of research papersto include in the review was determined by the availability of the fulltext of the articles found and the relevance of the subject studied tothis specific topic. Three further considerations were firstly, thatthe research discussed in detail would be contemporaneous, that iswithin a time span of the past ten years although earlier research isreferred to within the review, where this was adjudged to besufficiently influential and relevant to the issue under discussion. The second rationale, felt by the review author to be important, wasthat the research used would be that which was presented in a coherent,understandable and accessible way. Connected to this was the thirdimportant consideration, in that research material was selectedaccording to its validity and standing within the academic community.This was determined by the extent to which the researchers hadexplained their research design, methodology and analysis and whetherthe material had been cited by other well-established investigators inthe field. Decisions about how the review was to be organised, in terms ofgrouping the material, proved to be quite a difficult task due to thewide range of specific research aims and approaches found within thisfield. It must be stressed that the following four chapters representonly one way in which this material could be organised since there aremany issues and themes which tend to cut across all the studies,defying any rigid categorisation. Nevertheless, having considered allthe material, the chapter contents reflect the major themes to emergefrom the available literature from the past ten years. Two appendicesare included at the end of the review which outline the searchingstrategy used and its outcome, and the major themes emerging from thereview. Chapter Two Models of healthy mourning and the developmental perspective The death of a parent, and indeed any other significant figure, isunderstood as a very stressful experience for children. Worden (2003)notes the considerable controversy over some decades concerning theextent to which children are considered capable of mourning. He citesWolfenstein (1966) who suggested that children could not mourn untilthey have achieved full psychological differentiation within a fullyformed identity occurring at the end of adolescence. Others, hesuggests, such as Furman and colleagues (1974) and John Bowlby (1960),cite the age of capacity for mourning as much younger, at 3 years ofage and 6 months respectively (Worden, 2003). Worden himself assertsthat children do mourn and that the issue is rather that we need tofind a model of mourning that is appropriate for children themselves,rather than trying to fit childrens experiences into an adult model. Parkes (1986) and Worden (2003) have emphasised that mourning thedeath of a significant figure is characterised by a series of tasks tobe undertaken by the bereaved person over a period of time that isessentially unique to each individual. These tasks are summarised byBrown (1999) as accepting the reality of the loss, experiencing thepain of grief, adjusting to a new environment and investing in newrelationships (p.1). Brown (1999) points out that there are manyfactors which influence bereavement for children including their age,level of cognitive understanding and the relationship which they hadwith the person who died (p.18). She describes how these factors willimpact upon the childs emotional and behavioural responses to theirloss. John Bowlby, in his studies of attachment, loss and separation andaccompanying anxiety responses in children, asserted that bereavedchildren who had experienced secure relationships prior to the death,were more likely to achieve a healthy resolution to their loss (1969;1980). Furthermore, in his analysis of childrens responses to thedeath of a parent, Bowlby seems to place the responsibility for ahealthy resolution firmly with the significant adults around thechild. He suggests, for example, that the child is likely to behindered in his or her grieving process because the adults themselvesare often unable to bear the pain of mourning perhaps that of theirown mourning, certainly that of their childs, and especially that ofmourning together (Bowlby, 1980, p.272). Bowlby identified three key stages in the achievement of healthyresolution of childhood grief. Firstly, children need to be givenhonest and open information about the death, and to have theirquestions answered. Secondly, they need to be aware of adultsresponses to the loss and to be actively involved in the ritualssurrounding the death. Thirdly, they need a secure, continuedrelationship with a known and trusted adult (Bowlby, 1969; 1980).Bowlbys observations are given prominence here because they haveunderpinned much of the later work on childhood bereavement. Brown(1999), for example, outlines research evidence which emphasises thatthe most effective way to help bereaved children is to work with thefamily. She notes, also, that children adapting to grief need bothcognitive and emotional understanding of what has happened (Brown,1999, p. 18). Worden (2003) echoes this observation, pointing out thata certain level of cognitive development is required to fullyunderstand and integrate t he concept of death. He cites some of themajor cognitive concepts to be mastered as (1) time, includingforever; (2) transformation; (3) irreversibility; (4) causality; and(5) concrete operation (Worden, 2003, p.160). Worden (2003) describes the Harvard Child Bereavement Study whichhe, along with his colleague, Dr. Silverman, conducted in the early1990s with a total of 70 families, including 125 school-age children,over a two-year period following the death of one parent. Thenon-clinical sample of families was drawn from communities of varyingdemography and compared with a matched control group of non-bereavedfamilies. The researchers interviewed the children and survivingparents with the aim of studying the natural course of bereavementfor the children (Worden, 2003, p.160). Worden lists ten of the keyfindings from this survey study, the first of which is that mostbereaved children (80%) were coping well by the first and secondanniversaries (2003, p.160). The differences between the bereavedchildren (20%) who were not coping well and their control counterpartswere greater at two years than at one year, indicating that there was adelayed effect of the loss on these children, as pointed out by Word en(2003). This finding implies that childrens grief is developmental,fitting with the idea that the quality of childrens grief will changeover time, in line with their increasing mastery of the cognitiveconcepts mentioned earlier. The Harvard Child Bereavement research is cited as significant by anumber of commentators. Monroe (2001), for example, suggested thatthis study is probably the most important research study on childrenand bereavement to date (p.76). Monroe describes how children are aptto return to issues concerning bereavement and loss repeatedly overtime, especially at times of transition in their lives, as theirunderstanding develops and their questions change. Other key findingsfrom the research include the importance of active coping, cohesion andgood, open communication about the dead parent within the families.The most powerful predictor of a childs adjustment to the loss ofparent was stated as the functioning level of the surviving parent.Children with a poorly functioning parent showed more anxiety anddepression as well as sleep and health problems (Worden, 2003,p.161). This observation takes us back to Bowlbys assertion that aprime task in helping a child to overcome difficulties in the gri evingprocess is to provide the surviving parent with a supportiverelationship (1980, p.273), and this is a recurrent theme to which wereturn, especially in Chapter Five. A recent study conducted by Hurd (2004) contrasts with the Harvardresearch in many ways. Hurd employs a qualitative, single case-studyapproach in order to investigate the grief work of a 14-year old girlwhom he names Debbie. He describes his use of the interview method,audio-taping and transcribing all interviews into verbatim texts. Themode of data analysis used was the constant comparison method in whicheach interview session was coded for concepts, categories and majorthemes. Hurd describes his role as an engaged but dispassionatelistener committed to faithfully reporting and explicating (Debbies)bereavement experience and its meaning to her (2004, p.342). Datavalidity was established via interviews with Debbies mother andbrother to confirm factual accuracy. This differs from the surveymethod employed by the Harvard study in that it can produce therichness and complexity of individual experience in a way that theformer cannot. However, on the other hand, its limit to a single stud ycannot offer the kind of general overview of experiences within alarger population that the survey method allows. Recent commentators, such as Jacobs (1999) and Stroebe et al(2001), contribute to an ongoing debate that questions the perceptionof grief reaction as a psychiatric disorder, and therefore as somethingthat can be diagnosed and cured, rather than a natural response to theway that the death of a significant other can change a personsworld. Stroebe et al (2001), for example, have stressed the potentialfor healthy mourning during childhood after a parental death. Hurd,also, acknowledges the work of Bowlby (1980), stating that depressionas an outcome of a childhood bereavement experience was no longerconsidered as inevitable (2004, p.341). He also links this shift withan emergent contemporaneous interest in resilience in the lives ofat-risk children in this field, noting that there is, to date, verylittle research evidence on resilience in parentally bereavedchildren. From his single case study, Hurd concluded that Debbie was a stable andhappy 14 year old who had coped well with the loss of a much-lovedfather without having developed depression or other psychologicaldisorder. He notes the environmental factors deemed by Bowlby (1980)to be crucial for healthy mourning, as outlined above, and that thepositive presence of these in his analysis could help to explainDebbies success in coping. Hurd summarises by suggesting that theinternal and external protective factors were in place for Debbie tobecome a resilient adolescent able to experience healthy mourning andto develop her identity relatively unscathed by the psychological andemotional trauma that often accompanies a major loss (2004, p.351).Hurd ultimately calls for more single-case reports and large populationstudies enrich the knowledge base on resilience and suggest newdirections. Chapter Three Anticipated versus sudden parental death Many commentators have made a distinction between anticipated andsudden death in terms of the nature of grief responses. There seem tobe few studies which focus specifically upon childhood bereavement inthis respect, and where they do so they tend to be situated within thecontext of high-profile, public events such as the violence stemmingfrom the troubles in Northern Ireland, the September 11 attack on theWorld Trade Centre in New York and the genocide in Rwanda. Suchstudies, nevertheless, enhance our understanding of the specific impactof traumatic parental death upon children. Christ (2005) highlightshow the sheer numbers of parentally bereaved children following the 11September 2001 attack in New York prompted a range of novel groupinterventions with children and their surviving parents using ritualsand activities. These initiatives were centred upon the reconciliationprocesses of children at different cognitive and emotional levels,especially in the months following the death. Grace (2005) reviews the research into the relationship betweengrief and trauma responses in children. She notes that whilst earlierinvestigators stressed the need for the child to resolve the symptomsof trauma, where present, prior to being able to process bereavementissues successfully, more recent research suggests that the presenceof symptoms of trauma may not interfere with the childs ability togrieve (Christ, 2005, p.101). She cites evidence from her own workwith families of New York fire fighters who died which showed thatsymptoms associated with bereavement and trauma in children were oftenintertwined, suggesting that the two need to be addressedsimultaneously. Donnelly and Connon (2003) presented the findings from the childbereavement project group for the Social Services Trauma Advisory Panelin Belfast. They note that traumatic bereavement varies in nature andintensity as children grow and can also lead to the development of posttraumatic stress disorder and depression. Their research alsoidentified a number of children who were able to make use of bothsocial support and their internal resources to achieve understandingand cope with their grief without developing overwhelming symptoms orrequiring external interventions. Whilst acknowledging the usefulnessof resilience theory, emphasising the ability of children to cope wellwithout intervention, and other insights from research studies,Donnelly and Connon maintain that our current understanding oftraumatic bereavement underestimates the negative symptoms suffered bychildren (2003, p.3). They suggest that many researchers have reliedon assessing behaviours that do not accurately reflect the true rangeof childrens reactions (2003, p.3). Donnelly and Connon (2003), similarly to previously citedresearchers, acknowledge Bowlbys assertion of the loss of a parent, orprimary care giver, as one of the most influential events in a childslife, requiring radical adjustment to the childs daily routinealongside the establishment, or reinforcement, of a secure relationshipwith a trusted adult (Bowlby, 1980). They highlight the effects oftrauma on children, initial reactions depending upon the childs levelof exposure to the event, varying from hearing about it second-hand towitnessing, or being personally threatened by, the traumatic eventitself. They point out that the impact of trauma upon children can beso strong that emotions and thoughts about the event can remain vividfor years after the event and the threat have passed. Donnelly andConnon cite research by Terr (1991) which postulates traumaticbereavement as a particularly complicated process whereby the normalmourning rituals and social support which facilitate the resolut ion ofnon-traumatic bereavement are often not enough to overcome distresscaused by traumatic loss(2003, p.5). They go on to stress that iftrauma remains unresolved, or isnt fully understood by children, itinterferes with the normal grief process, engenders secondarydifficulties, and increases the period of distress (Donnelly andConnon, 2003, p.5). Many commentators, such as Brown (1999) and Worden (2003), point outthat bereavement is especially difficult when the death was sudden orviolent. The age of the child is important also; Brown (1999) notesthat where death has happened suddenly, many children will recallevents which immediately preceded the death, examining conversationsand their own relationship with the person in great detail (p.28).Brown records the observations of researchers such as Adams (1992), whopointed out that, for young people, a particularly difficult aspect ofa parents sudden death, often overlooked and misunderstood, is thatdeath and grief involve feelings of helplessness and lack of controlthat are exceptionally difficult to cope with when you are at preciselythe stage in your own life when you need to feel powerful and incontrol (1999, p. 28). Some researchers have addressed childhood bereavement within amedical model, emphasising the pathological features of certain griefresponses. Pfeffer (2000), for example, cites many research studieswhich stress how depressive symptoms seem to be the most consistentadverse outcome in bereaved children. He describes one study of 38children in which one-third of them suffered symptoms of majordepressive disorder within the first two months after parental deathfrom such causes as cancer, cardiopulmonary arrest, stroke or accident,and that these depressive symptoms lasted up to 14 months afterparental death in many cases (Pfeffer, 2000, p1). Pfeffer (2000)differentiates between grief following anticipated deaths, from cancer,for example, and grief following unexpected or violent forms ofparental death. Pfeffers study focused upon child survivors of parental death of twoparticular types, cancer (57 families, 64 children) and suicide (11families, 16 children). Children in both samples completed aself-report questionnaire, the Childrens Depression Inventory,described as an established and valid measure, within 18 months of thedeath. The data from both samples was compared using statisticalanalysis methods. Pfeffers findings indicate that althoughchildrens grief after all forms of parental death is characterised bysymptoms of depression, there are additional reactive symptomsfollowing sudden death, particularly suicide. These include severeanxiety, hyper arousal, and intrusive thoughts within the first yearafter parental death and the formation of childrens traumaticexpectations about the world and a sense of worry about personalintegrity and the security of interpersonal relationships(Pfeffer,2000, p.2). Chapter Four Long-term implications and retrospective studies Several researchers have demonstrated the increased risk ofdeveloping psychological and social difficulties in later life forchildren who have lost a parent through death (Weller et al, 1991;Black and Young, 1995). Some researchers have chosen to explore thelong-term consequences of childhood bereavement through conductingretrospective studies of adults, in contrast to those studies,highlighted in Chapters Two and Three, which primarily focus onchildren. Hurd (1999), for example, sought to discover how adults whohad been parentally bereaved in childhood had incorporated theexperience into their lives. Hurd was interested in the adequacy oftwo well-established, and contrasting, theories for explaining howyoung children cope with the death of a parent, and the implicationsfor their future mental health. Was the Freudian theory thatdepression is an inevitable consequence of the childhood bereavementexperience accurate? Or, did Bowlbys thesis of a more positive outcomefrom potentially he althy mourning fit better? Hurd (1999) used Q methodology, making use of both quantitative andqualitative measures, and including factor analysis, to organise andanalyse the subjective experiences of his 43 respondents. He foundthat 19 of the participants described their experiences of seriousdepressive illness at some time during adolescence or adulthood,another 19 recorded having never been depressed and none of them weredepressed at the time of the interview. Hurd concluded that the viewheld by Freudians of later behaviour and affective disorder was notconfirmed by the study (1999, p.31). In contrast, the data analysisconfirmed Bowlbys prediction that children were more likely to resolvetheir grief in healthy ways during childhood, reducing the potentialfor later depression if they have loving relationships with theirparents, if they experience strong emotional support from the survivingparent after the death occurs and are consulted during decision-makingabout the familys future, and if they experience the support ofextended family and others (Hurd, 1999, p.32). Hurd acknowledged the limitations of the study, such as reliance onself-reports by participants and the absence of validity confirmationregarding their childhood experiences and depression. Indications forfuture research include exploration of the role of siblings in thegrieving processes of children and longitudinal studies to explorefurther significant influences over time. Maier and Lachman (2000) observed that few research studies havebeen conducted into the long-term consequences of childhoodexperiences, including parental death, although, where they exist, theytend to focus upon the relationship between early parental death andspecific types of psychopathology in adulthood. Maier and Lachmansapproach is somewhat different from that of Hurd in that they chose tosurvey a large population sample to investigate a wide range offactors. Their study involved telephone interviews with a largesample, described as a national probability sample, of 4242 adults inthe USA. The respondents, aged between 30 and 60, completed aquestionnaire which was subsequently analysed according to measures ofmental health, depression, physical health, social support and natureof parental loss and separation. The research aim was to chart the consequences of early parental lossand separation for health and well-being in mid-life. One finding wasa stronger effect, in terms of mental and physical health anddepression, of parental divorce than for parental death in mid-life(Maier and Lachmann, 2000, p.188). The researchers conclude, in termsof early parental death, that greater autonomy was indicated for men inmid-life whilst depression was a more significant factor for women.However, they state that it is still unclear how parental divorce anddeath may differentially impact men and women (Maier and Lachmann,2000, p.189) and further research is flagged up for this particulararea. Another survey study was carried out by Mack (2001) of similar sizeto that of Maier and Lachmann (2000), using the self-completed reportsfrom 4,341 respondents for the analysis. Mack was also concerned tocompare adults who had experienced parental divorce with those who hadexperienced parental death prior to the age of 19. Mack is critical ofresearch on one-parent families that often has failed to distinguishbetween the effects of different types of family disruption upon adultwell-being. He points out that such research has typically notrecognised the possibility that events such as parental divorce orparental death are diverse experiences that are likely to affectchildren in very different ways (Mack, 2001, p.419). Mack draws on Bowlbys (1980) assertion that parents play animportant role in determining childrens responses to traumaticevents. He also refers to the social learning theory of Bandura (1971)which emphasises that children learn certain responses to stressthrough observation of parents and other significant carers. As Mack(2001) notes, accordingly, parental reactions to stressful events,such as divorce or death of a spouse, are particularly important indetermining how children develop responses to these same events(p.420). Mack suggests that these two theoretical approaches underpinhis own thesis that different types of childhood family disruption willdetermine qualitatively different outcomes for adult well-being. Thevariables used in Macks study to explore this theme were parent/childrelationship quality, self-confidence, depression and childhood familystructure and survey responses were analysed using statistical methods. Mack (2001) found that adults who had experienced early parentaldeath did not report significantly different parent/child relationshipsfrom those raised in intact families, contrasting with the negativeeffect found for parental divorce on parent/child relationships.Consistent with prior research, Macks study found that when comparedto adults who had been raised in intact families, adults whoexperienced parental death report lower levels of self-confidence andhigher levels of depression (2001, p.438). Whilst acknowledging thatnot all bereaved children and their parents necessarily respond in thesame way, Mack nevertheless makes a useful connection between his twokey background theories and the findings from his study. He observesthat regarding parental death, if permanent separations produceattachment-related feelings of despair and children also observe highlevels of parental guilt and sadness, then we should not be surprisedto find that these individuals have low confidence and symp toms ofdepression as adults (2001, p.438). Chapter Five Service Provision An exploration of the available literature on this topic revealsthat there is no shortage of advice and guidance for parentallybereaved children and their families from a wide range of sources.There are a number of accessible books aimed at children to help themunderstand and manage their feelings regarding loss and bereavement,for example, Michael Rosens Sad Book by Michael Rosen (2004),Remembering Mum by Perkins and Morris (1991) and It Isnt Easy byConnolly (1997). There are also books offering advice and support toparents coping with children in the context of bereavement and loss.For example, a book called Coping with Loss for parents by Elliot(1997) covers themes such as how bereavement, loss and change areconnected, how children think about death according to age, how aparents own grief impacts on his or her child and how to support agrieving child. In similar vein, a book by Wells (2003) covers thebroader perspective of children and loss, addressing the impact ofmajor losses, including parental death, as well as disability,ill-health and family traumas and how these affect children atdifferent ages within the family context. Service provision in the UK for children who have been parentallybereaved has been reviewed and researched in recent years and two ofthe key studies will be outlined here. Dowdney and colleagues (1999)sought to identify whether psychiatric difficulties in parentallybereaved children and surviving parents were related to serviceprovision. Using a representative community sample of 45 bereavedfamilies with children aged between 2 and 16 years from two Londonhealth authorities, they conducted a semi-structured interview witheach family. Information was gathered on the death, familial grievingactivities and adjustment of family members after the death togetherwith details of external bereavement support sought, offered andreceived by the family and children. Standardised checklists werecompleted by the parents to assess emotional and behaviouraldisturbance in the children and, for school-age children, by theteachers. Parental mental health was determined through a generalhealth questionn aire and probable psychiatric disorder wasidentified. Dowdney and colleagues found high levels of psychologicaldisturbance in the children and surviving parents during the 3 to 12month period after the death. Boys presented with greater symptomaticbehaviour than girls, particular through aggression and acting out(Dowdney et, al 1999). In terms of service provision for bereavedchildren, this was unrelated to probable psychiatric disturbance inchildren or parents or to parental desire for support and theresearchers concluded by suggesting that given resource limitations,service provision should be targeted at psychologically disturbedchildren or psychiatrically disturbed patients wanting parentingsupport, or both (Dowdney et al, 1999, p.?). It seems clear that Dowdney et als study, like that of Pfeffer (2000)described in Chapter Three above, adopts a medical model, viewing childand family bereavement responses and behaviour in pathological terms.It is interesting to note that they give no reference to the healthymodels of mourning, or natural processes of grief that have beenacknowledged by other authors, such as those outlined in Chapter Two ofthis review. Their focus is firmly upon those parentally bereavedchildren and families whom they have deemed to have shown psychiatricdisturbance and, therefore, service provision is viewed as necessaryonly within this context. A comprehensive survey of UK service provision for childhoodbereavement was carried out more recently by Rolls and Payne (2004).91 known services received postal questionnaires and from theresponses, 8 organisations were selected to be studied as in-depthcollective case studies. Both quantitative and qualitative researchmethods were used to analyse the data. Whilst services had a sharedobjective to help bereaved children, they were found to be very diversein terms of their location, type of services, service organization,management and funding arrangements, staffing types and levels and, toa lesser extent, types and range of interventions offered (Rolls andPayne, 2004, p.320). It was observed that since bereaved children werenot defined as children in need under the Children Act 1989, servicesaimed specifically for them were struggling financially in the face ofuncertain funding sources. It is also the case, however, that underthe present government initiative the Childrens National ServiceFramework standards are currently being defined to support thedelivery of services concerned with enhancing childrens mental healthand well-being. It is envisaged that childhood bereavement serviceswill respond to meet these. The Childhood Bereavement Network (CBN) is an umbrella federation ofservices, established in 1998, working in a variety of settings withbereaved children, their families and caregivers. Having secured threeyears funding from the Community Fund, the CBN aims to improve accessfor bereaved children, their parents and other caregivers throughoutEngland to a wide range of high quality information, guidance andsupport, including counselling (CBN, 2005). Other publicised resources include the charity Winstons Wish,begun in the mid 1990s, which has published a Charter for bereavedchildren. The Charter promotes respect for the rights of bereavedchildren in a number of areas, including bereavement support, theability to express feelings and thoughts associated with grief, toremember the person who has died, to receive information and educationand to have a voice in important decisions affecting their lives(Winstons Wish, 2003). The National Childrens Bureau, awell-established childrens charity, has also published its Guidelinesfor Best Practice for Bereavement Care for children and runs a websitegiving information about services, new initiatives and researchundertaken. Chapter Six Discussion and Conclusion Several themes and issues are raised by this review of the evidencerelating to the effects of parental bereavement in childhood. Firstly,the work of John Bowlby (1969; 1980) on issues of attachment,affectional bonds, loss and bereavement in childhood has clearly beenhighly influential in the research and commentary on this topic. Therewere references to Bowlbys theories in almost all the research sourcescited. Particularly pertinent, it seems, is Bowlbys notion ofhealthy mourning, that successful mourning in children can lead to ahealthy resolution of their loss and need not lead to psychologicaldisturbance in later life. The research studies of Worden (2003) andHurd (2004), cited in Chapter Two, while making use of contrastingmethodological approaches, illustrate this latter point effectively.Secondly, the developmental nature of childrens understanding ofdeath, and ability to cope with the loss of a parent over time, seemsto have been a key message from Wordens research, marking ou tchildrens bereavement as qualitatively different from that of adults. The theme of healthy mourning versus pathological mourningpermeated many research studies. It seems that there are many morestudies that focus on the detrimental psychological outcomes ofchildhood parental bereavement, both in children and in adults, thanthose which study healthy mourning. Studies of the former, notably,use terms such as psychological disturbance and psychiatricdisorder (Dowdney et al, 1999; 2000) and major depressive disorder(Pfeffer, 2000). Other examples of such research relating tochildhood parental death, found through a search on the internet, butnot described in this review, include phrases such as attachmentstyles and personality disorders (Brennan and Shaver, 1998),psychological symptomatology (Thompson et al, 1998) and earlyparental loss and psychiatric illness(Agid et al, 1999). It was muchharder to find research which sought to explore the normal course ofchildhood parental bereavement, with one or two exceptions. Worden(2003), for example, cited in Chapt er Two, found that 80% of thechildren in his study, who had been parentally bereaved, were copingwell by the end of the first and second year after their loss. Itwould seem, as some commentators have noted, that more work is neededinto children who do well after the death of a parent (Brown, 1999,p.28). Dowdney (2000) observes, from her review of the research literature,that there is continued support for the association between parentalloss, childhood disturbance and later psychiatric disorder,particularly depression, borne out by the findings in this review. Shepoints out that the strongest evidence for this tends to come fromretrospective studies of adults with mental health problems. However,many studies have not found this association, for example, Hurd (1999)and Mack (2001) cited in Chapter Four of this review, challenging thevalidity of this link. Dowdney (2000) points out that someresearchers, such as Tennant et al (1980) and Harris et al (1986), andthe study by Mack (2001) described earlier in this review, argue thatchild bereavement alone is unlikely to be associated with adultpsychopathology, including depression. It seems more likely to be thecase that, as Dowdney concludes, it is the factors associated withbereavement, such as the quality of parental care and the presen ce ofother adverse social and economic sequelae following the bereavement,that influence adult outcome (2000, p.819). The research on differences between anticipated and sudden parentaldeath for the bereaved child appears to be a relatively new field ofenquiry with some interesting findings, as outlined in Chapter Three.One of the key issues to emerge in this area is the debate around thedegree to which symptoms of bereavement and trauma are interconnected,as outlined by Christ (2005) and, therefore, whether interventions tohelp severely affected children need to be focused on thesesimultaneously or separately. Comparisons between the findings of the research studies outlined inthis review seem to be fraught with difficulties, largely becausemethodologies, sampling, research questions and design vary widely,making it hard to compare like with like. There are, unsurprisingly,conflicting conclusions, for example, regarding the manifestation ofdepressive illness later in life as a consequence of childhoodbereavement. There seems little doubt that, as Dowdney (2000)suggests, Commonly, bereaved children present with a wide range ofemotional and behavioural symptoms that constitute a non-specificdisturbance (p.827). A small, but significant percentage of thesechildren are likely to be sufficiently distressed to justify referralto specialist services (Dowdney, 2000; Worden, 2003). A number of theresearchers cited have highlighted the need for longitudinal studies toassess more accurately both the nature of childhood parentalbereavement itself and the extent of psychological vulnerability overtime. The qualitative case study undertaken by Hurd (2004) described inChapter Two is one example of research which can provide a rich,in-depth description of the experiences of one young person who hadbeen parentally bereaved. In the absence of large samples of recentlybereaved children, it seems that the development of rigorousqualitative methodology such as this latter study will be useful toprovide a framework for future empirical studies. Finally, the findings of researchers such as Mack (2001) suggestthat it may not be childhood parental bereavement per se that leads toprolonged or future psychological disturbance but any number ofexternal factors that may accompany this particular phenomenon. AsDowdney (2000) suggests, more research is needed to investigate theinfluence of variables that may mediate, or facilitate, the outcome forthe bereaved child. There may be individual child factors such astemperament or disposition, family and school factors and also the manylife events that may follow parental death (Dowdney, 2000, p.828). 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