Few more traumatic experiences than losing a parent to suicide exist. In the aftermath, we all need to muster to help the child through this experience. In this article, the role of health care personnel will be discussed.
Suicide is one of the main causes of death among the younger population and a considerable number including children are annually bereaved by parental suicide. The risk of adverse short- and long term outcomes are increased (1). Several studies have demonstrated risk of profound and potentially long-lasting effects and development of psychosocial and psychiatric problems, particularly depression and anxiety disorders including generational transmission of suicidal- and self-harming behavior (2-5). Psychiatric history, particularly mood disorders, constitutes a substantial number of suicides (6) and is risk factor for suicide in young people, and especially elevated in maternal psychiatric illness (7).
Some suggest that the impact of parental suicide death can be associated with more severe and long-lasting problems in comparison to natural deaths. Child survivors of parental suicide are left with the challenge of not only of trying to understand why their parents died by suicide and why they chose to leave them, but also of coping with the social stigma of a suicidal death. Even though church rules change decades ago to allow people that died from suicide to be buried inside graveyards, stigma and negative social attitudes are inevitably still a challenge for suicide survivors (8, 9).
Bereavement in children and adolescents
In addition to the loss a primary attachment figure, children’s grief depends on development stages and concepts of death. The grief often come in sudden waves and changes in line with their perceptions and understanding of the circumstances (10).
Children’s reactions to death in general can be depression, anxiety, concentration problems, withdrawal and insecurity. In some cases, complicated grief or post-traumatic stress disorder can occur, especially when the child witnessed violent or traumatic suicides. However, even if the child did not witness the death, it is common for them to experience symptoms of post-traumatic stress from imagining their parent at their very worst. Further common general reactions in suicide bereaved are feelings of rejection, shame, guilt, suicidal ideation, anger, relief, and a continuous search for explanation (11). This is also complicated by individual or societal stigma because it add unique stress on the bereavement process that in some cases requires clinical intervention (12).
Postvention
Postvention refers to activities or interventions occurring after a death by suicide, to support those bereaved or affected. A wide variety of interventions, including, supportive, therapeutic and educational approaches as well as those involving the social environment of the bereaved (13). In a recent published literature review we found that the field of suicide postvention remains relatively immature and research specifically in interventions for suicide bereaved children is scarce (9). While many children who experience the suicide of a parent do not experience persistent high levels of stress (14) and many are resilient and not in need of specialist interventions to prevent long term consequences (15), there are some children who need specialized care and health care professionals can find it difficult to deal with grief and especially suicide bereavement (16).
How can clinicians find information of appropriate and effective techniques to guide their help in the meeting with suicide bereaved children?
General bereavement theory and counselling approaches are necessary to provide customized care (17, 18). This include general relational skills from grief -and psychotherapy in addition to an empathically attuned professional position able to provide a healing, understanding and supportive context (19) In certain incidents, and especially in violent suicides, the risk of PTSD symptoms are increased (20) and trauma informed care should be considered. This applies even if the child did not witness the suicide or see the body as they have imagined what might be worse than the actual trauma. A full review of the current literature included immediate post suicide interventions is out of scope for this paper, but some special features and clinical implications of parental suicide bereavement will be discussed.
It is important to tell the truth and be clear and honest about why and how the parent died. The child’s levels of perception and needs are therefore important to considerate when providing age-appropriate information. Suicide bereaved often have a greater need to understand the death and the different life circumstances and situation leading to the suicide. This also include cases associated with psychiatric illness.
Losing a parent that lived in a situation where they ended their life often adds the burden of rumination, self-blaming and scrutinizing. Suicide bereaved often feel guilt and wonder whether they should have done something different. Questions like “Should I have seen this coming?”, “Why did my parent choose to die?” and “Should I have acted differently” are common.
Bereaved need to validate their thoughts and feelings like blame, guilt, anger and relief as normal. The feeling of guilt can be related to questions like, “Was it my fault?”. Apparent lack of feelings and phrases like “I’m just fine” might indicate the opposite. The feeling of rejection among the bereaved is a potential pit fall clinicians should be aware of especially since the feeling of stigma and shame might hinder actively professional support seeking (21). One of the consequences may be that they don’t cope and process the aspects of the loss by talking about their feelings and thoughts (18).
In some suicide bereaved families, the communication skills are poorer when it comes to address feelings and are often associated with avoidance and help seeking problems (18, 22). Qualitative research of bereaved children have underlined the importance of professionals being persistent and continue to offer support even if the child initially refuses help (23). Sometimes it is necessary to dig deeper, build trust and elicit conversation on the child’s lead (24). To let the child be actively involved in own grief work and provide hope in the process is an active part of all strategies that assist children in making a coherent self-narrative, integrate the loss and move forward. Focus should not be on emotional and physical challenges but construct a meaningful narrative of the world with faith in security, predictability, trust and optimism. By adding memories of happier times despite the difficult situation can aid coping and create a broader narrative of the family history (18).
Expressive therapy, like writing or sharing experiences in grief groups or camps can foster narratively construct and destigmatize understandings of suicide in addition to relieve of self-blame and shame (18, 25).
Family perspective
The loss of a primary caregiver can trigger a wide range of structural and relational changes and result in a different family situation and series of negative outcomes (14). Secondary losses can be economic problems, change of residence, school and change of social network. the other grieving parent might need support to take care of the child(ren) and other household duties for a period. It has been revealed that social support in general, included parental support and family-oriented interventions fosters mental health when parents are given enhanced capacity to support their children (26).
Grief theory
There has been a shift in grief theories in children, from early Freud’s psychoanalytic perspective on mourning and Bowlby’s attachment theories from a linear process into a more dual process where the coping with grief as an oscillation between loss-oriented and restoration activities for the child (9, 18).
Grief sometime resurfaces later in life, at special times of the year, the day of the suicide, or related to happy events like birthdays, childbirth or weddings and manifested differently. Reaching the age the parent died also can become stressful (27). Also fear of inherit mentally illness or suicidality can occur. Continued short- and long-term awareness is important and should be kept in mind when meeting adult patients with childhood experiences of suicide in primary and specialist health care.
National guidelines and resources
In line with the WHO and UN, action plans and guidelines for suicide prevention that include postvention for suicide bereaved children have been launched in several Nordic countries. Several international institutions also provide web resources for clinicians of grief and suicide bereaved. The Norwegian Directorate of Health have published guidelines for crisis help to families and children immediately after suicide (28).
Given it is highly likely you will encounter a suicide bereaved child, it is important to be prepared in order to best help them. Clinical experience, tailored interventions together with updated research and guidelines will be helpful. □
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