The role of paediatricians in implementing adequate social programs to assist children suffering parental loss.

Parental loss in children describes several circumstances, which besides death, are related to a prolonged absence of one or both parents or caregivers. Separation from familiar figures due to divorce, incarceration, prolonged absence for work or removal to foster care, are only few of the several factors that have been identified to contribute establishing a condition of parental loss.

During recent years the cases of parental loss have progressively grown among children living in the European area, likely reflecting substantial changes in the civil society, mainly related to several social, economic, cultural and technological trends that have impacted the traditional family structure, particularly during the last few decades. To this regard, factors like the recent 2008 economic turmoil and a progressive dissemination of undifferentiated and globalized social models have further favored the increasing negative impact of parental loss in children living in the European countries. In fact, the progressive homogenization of social and welfare programs, proposing generalized solutions to specific issues, seem to be often unable to effectively integrate at local level with the typical cultural diversities characterizing the various European social backgrounds. Social interventions applying the same operational models in different countries, appears in many circumstances insufficient to properly assist children coping with parental loss. Therefore, suggesting that the “one fits all” type of approach to deal with social challenges, may not provide efficient and long lasting solutions.

The authors of this commentary are part of a social pediatrics working group supported by European national pediatric societies (Turkish Paediatric Association, Italian Federation of Paediatricians, Romanian Social Pediatrics Society, Italian Society of Paediatrics) member of the European Paediatric Association, the Union of National Pediatric Societies and Associations (EPA/UNEPSA). The commentary aims at further raising the attention of pediatricians on the increasing impact of parental loss on children’s life and in particular on their present and future health and wellbeing. To this regards the working group emphasizes the importance of assisting children challenged by parental loss, with adequate social programs of prevention and support, as well as the role that paediatricians may play in implementing these interventions. Such programs should be designed to properly adapting to different local needs, taking in account the cultural diversity and social backgrounds characterizing the Nations of the European area, in which families differs from culture to culture and from one nation to the other.

Definition of parental loss

Parental loss, in its wider meaning, also includes the concept of separation variously articulated in its several dimensions. Currently, there is no unifying definition of parental loss reported in literature. Parental loss is in fact the result of several different elements and independent circumstances, which are often difficult to be correlated. Whatever the cause, the impact of parental loss on the health and well been of children, seems however to be significant and possibly playing an important role in the pathogenesis of pathologic conditions in adulthood. For instance, parental loss has been associated with a variety of psychiatric disorders in adulthood (1), including a range of personality disorders (2), anxiety (1), addiction to drugs and alcoholism (3), and particularly depression (3, 4). Recent studies have also described psychobiological alterations related to parental loss suffered in childhood, which could manifest their effects later in life (5–7).

Childhood parental loss and adult mental disorders

There is a wide range of findings reported in literature about the impact of parental loss on the mental health of individuals through their life, which appear in many cases conflicting. It is however a general accepted notion that parental loss is a stress-causing event (8). To such regard, a large number of animal and human studies suggest long lasting effects of chronic stress on the brain structure involved in psychiatric disorders (8), and that certain areas of developing brain show the existence of early windows of vulnerability that are most susceptible to adversity than others (9).

Childhood parental loss has been suggested by various psychodynamic and developmental theories throughout the years, to be a main determining factor in the geneses of affective psychopathology disorders (9). The debate around this relation is still open, as a considerable number of clinical reports have indicated an existing association of depression and anxiety disorders with early parental death and prolonged parental separations, while other studies have reported that childhood parental death or separation are not related with mental disorders (9). Such different conclusions reported in literature may be due to the presence of significant methodology variants adopted by the studies published in literature. Among them, the heterogeneous composition of control groups adopted in the different studies, and most of all the lack of consensus in defining parental loss, possibly due to the variety and difference of causal conditions, may have been an obstacle to formulate conclusive analysis on the impact of this condition in the development of affective psychopathology disorders. Further factors, such as age or gender of the individual or the loss parent have been also indicated to possible influence the risk for mental illness in the wake of parental loss, but the scientific evidence for this is currently considered inconsistent, due to the lack of convincing data (10).

Among the range of conditions included in the state of parental loss, the event of a parent’s death during childhood is certainly a most important traumatic experience that can frequently generate difficulties in adaptation and psychopathological problems occurring throughout the developmental age channels to the adulthood. The impact of parental death on children’s health it also influenced by several concurring factors. For instance, it is a commonly accepted concept that the likelihood of experiencing a different impact from parental loss varies by locality and social circumstances (11). To such regard, ethnicity, social positioning or material circumstances have received little attention, as for instance migrations, economic disadvantages and discrimination may increase the children’s vulnerability when dealing with parental loss. This can explain the absence of conclusive analysis for these factors, probably due to the scarcity of data about the long-term outcomes.

Thus while there is a consensus regarding the parental loss, considered in its wider meaning, been a stress causing events, a long lasting debate on its role in impacting children’s mental health, and in generating adult psychopathologies is still open, due to the complexity of this multifactorial condition.

Psychobiological alterations related to parental loss

Stress-related perturbation of immunologic processes have been related to adult risk for morbidity and mortality in disease susceptibility through inflammatory mediators with a dysregulation of immune-modulating systems (i.e.: the sympathetic–adrenal–medullary system and the hypothalamic–pituitary–adrenal axis) (5). Parental loss suffered during childhood has been associated to increased levels of inflammatory molecules shown by the same subjects during their adulthood, as well as a disproportion of inflammatory mediators has been reported in the occasion of illnesses (ie, asthma, cardiovascular disease and cancer,) (5). Furthermore, a lower output of hormone cortisol has been described in individuals who had suffered a parental separation, and elevated levels of the inflammatory marker C-reactive protein were also documented among individuals who had experienced parental separation during childhood compared with those who had not (6, 7).

Several reports from the literature also emphasize that parental loss and in general early life events play a role on the onset of childhood functional gastrointestinal disorders (12). These reports indicate that early life events represent a significant risk factors in the development of an abnormal response to pain during adolescence and later in adulthood. Experimental and clinical studies provide evidences that early childhood is a critical time period in which psychological or physical trauma can induce visceral hyperalgesia. The important notion that complicated pathogenesis of functional gastrointestinal conditions may be in part related to early life events it is of great significance, since a timely intervention by establishing adequate clinical and social programs, may have a critical impact in the prevention of this group of chronic incapacitating conditions.

Thus, significant evidence has been provided by literature for the link at a neurobiological level between parental death and risk for psychopathology. However, future larger studies which should include an extended control for confounding factors, may offer additional insights and further elements to expand the knowledge on the mechanisms of the effects of loss on the development and prevention of depressive and anxiety disorders.

Conclusions

The loss of parents, family members or caregivers in general has been documented to be a major stressful and disturbing experience for children (1). Parentally bereaved children are more exposed to functional impairment and other multiple negative outcomes, including psychobiological, behavioral and mental problems. The damage and suffering, experienced by individuals during childhood are amplified in adult life when appropriate levels of support are not provided timely (12). Mainly due to the multiple dimension of parental loss and the different social and cultural contexts in which this condition takes place, a diversity of frameworks and psychosocial interventions have been proposed (12). They consist in a range of different types of approaches which include, besides a classic pharmacologic therapy, self-help, family interventions, support groups, counseling, and community resilience groups (13).

In most cases the interventions are delivered by a multiplicity of professionals and para-professional figures (eg, psychologists, nurses, social workers, pastoral groups) in varied formats (ie. individual or group support meetings, home visiting programs, online or telephone support teams), which effectiveness showed small to moderate effects (14). However, it has been shown that support programs targeting high-risk children and starting closer to the loss they have suffered, have been more effective (14). To such regard a substantial number of studies indicate the importance of respecting a specific time-frames for initiating the interventions, which is indicated to be within a year and a half after a death or in general a loss is suffered by children. However, there is no general consensus on this point, as few studies suggest a time interval of 5 years post-loss to be sufficient in establishing effective supportive interventions.

The social pediatrics working group collaborating with EPA/UNEPSA on the effects of parental loss in children, would like to stress the importance for pediatricians to be aware of the impact caused by this condition on the well-being of children. Pediatricians and particularly family pediatricians should be part and help local public health care systems in planning social programs of interventions, which should be initiated early after the loss (15). In fact, early psychological and social interventions for bereaved children and their families have been described to be an effective mean able to prevent acute distress levels and future psychopathology, such as post-traumatic and complicated grief effects (13). bereaved children should be provided with early information and involvement. Finally, following the correct notion of the “family oriented approach” in pediatric care, effective support programs should include the whole family.