ARTICLES
CLINICAL PSYCHOLOGY

 

The death of parents by homicide and child grief: systematic review

 

La muerte de padres por homicidio y el luto infantil: revisión sistemática

 

 

Karolline J. S. Menezes; Juliane C. Borsa

Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil

Correspondence

 

 

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ABSTRACT

Parental death associated with violent circumstances has important repercussions for child grief, representing a risk factor for development. In this sense, this article aimed to identify, in national and international literature, the biopsychosocial characteristics involved in the grief of children from zero to 12 years of age due to the death of parents by homicide and the psychotherapeutic approaches applied in this context. Searches were performed in the databases: PsycINFO, PubMed, BVS-Psi, and Portal de Periódicos Capes using the keywords: grief, child, and homicide. The review was registered in PROSPERO (CRD42019120703). Around 158 articles were found, following the PRISMA recommendations for systematic evaluation. After analysis, seven articles constituted the final sample. There is a lack of studies on the subject. However, the sample indicated specificities of grief resulting from homicide and the psychotherapeutic interventions applied to this demand. Further studies on child grief due to parental death by homicide are suggested.

Keywords: child grief; death of parents; homicide; biopsychosocial characteristics; psychotherapeutic approaches.

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RESUMEN

Muerte parental asociada con circunstancias violentas tiene importantes repercusiones para luto infantil, lo que representa un factor de riesgo para el desarrollo. Así, esto artículo apunta identificar, en la literatura nacional e internacional, características biopsicosociales involucradas de luto de niños entre cero y 12 años debido la muerte de padres de homicidios y abordajes psicoterapéuticas aplicadas en este contexto. Búsqueda de artículos en bases de datos PsycInfo, PubMed, BVS-Psi y Portal de Periódicos Capes utilizando los descriptores luto, niño y homicidio. Esta revisión se registró en PROSPERO (CRD42019120703). Fueron encontrados 158 artículos. Siguiéndose las recomendaciones PRISMA para evaluación sistemática. Después del análisis, siete artículos constituyeron la muestra final. Constátese carencia de estudios sobre el tema. Mas, la muestra indicó especificidades de luto como resultado de homicidio y las intervenciones psicoterapéuticas aplicadas esta demanda. Se sugieren estudios adicionales sobre luto infantil debido la muerte parental por homicidio.

Palabras clave: luto infantil; muerte de los padres; homicidios; caracteristicas biopsicosociales; enfoques psicoterapéuticos.

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1. Introduction

Death can be considered taboo, especially in Western society, as it is neither debated nor treated as an inherent life-cycle process (Basso & Wainer, 2011). Commonly, the notion of terminality is perceived when the loss of a significant person occurs, and grief is understood as a natural and expected process in the face of loss, experienced from the uniqueness of each individual and their socio-historical context (Bromberg, 2000; Parkes, 1998).

Grief is considered one of the most intense pains that humans can experience (Tinoco, 2007). When the grief reaction is not treated, the grieving process can culminate in intense suffering, being associated with symptoms of anxiety, guilt, sleep disturbances, appetite changes, disorientation, memory difficulties, social isolation, and uncontrollable crying, among others (Breyer, Sanfeliz, Cieurzo, & Meyer, 2006). These symptoms are present in most individuals who experience the loss of a loved one and are usually characteristic of healthy mourning. However, when the intensity of symptoms increases and persists, grief can be understood as complicated (Parkes, 1998). In short, complicated grief means the manifestation of physical and mental symptoms that promote the denial and repression of pain due to loss and, consequently, make it impossible to recognize, readjust and invest in new bonds after the loss of a loved one (Parkes, 1998).

The grieving process resulting from violent death can generate feelings of anguish, pain, stress, disorientation, and perplexity in the surviving family members (Burke, Neimeyer, & McDevitt-Murphy, 2010). Due to its irreparable character and culmination in the complete denial of rights, homicide is considered a type of violent death that can promote significant personal and social repercussions (Costa, Njaine, & Schenker, 2017). Each homicide is estimated to directly or indirectly affect the lives of approximately seven to ten individuals, including family, friends, and neighbors (Costa et al., 2017). Post-traumatic stress disorder (PTSD) and depression are among the main impacts of death by homicide (Costa et al., 2017).

Considering the violence in the Brazilian context, statistics released by the Instituto de Pesquisa Econômica e Aplicada (IPEA) and the Fórum Brasileiro de Segurança Pública (FBSP), through the Atlas da Violência 2019 (Cerqueira et al., 2019), demonstrated the occurrence of 65,602 homicide deaths (a rate of 31.6 homicides per 100,000 inhabitants in the country) in 2017. Among the Brazilian states, Rio Grande do Norte showed an increased rate of this cause of death (+17.7%), while Rondônia decreased (-22.0%). There were 35,783 homicides of youths (69.9 per 100,000 youths in the country). Also, 75.5% of homicide deaths in 2017 occurred among the black population (i.e., black and mixed-race people), in whom the homicide rate increased by 33.1% between 2007 and 2017. It is noteworthy the growth in the homicide rate of women in the country in 2017, with a total of 4,936 women victims (equivalent to 13 deaths per day). Finally, the rate of homicides by firearms was 72.4% in 2017, indicating an increase of 26.9% from 2007 to 2017 (Cerqueira et al., 2019).

Like adults, children are also impacted by the experience of grief and may have particular responses to loss. These reactions may be influenced by the way the adults understand death (Walsh & McGoldrick, 1998). Likewise, the way adults experience grief can directly influence a child's emotional reaction and how they assimilate their own grief (Andrade, 2013).

The case is even more delicate when it comes to the premature death of one or both parents, representing a risk factor for the child's physical and mental health (Parkes, 1998). Such an event, when it originates in a homicide, offers even greater risks to the child than natural death, which is generally not as traumatic (Domingos & Maluf, 2003). Associated with the sudden and violent character, the impact of the parents' deaths resulting from homicide is reflected in significant physical, emotional, intellectual, and social changes in the child's life and grief process (Parkes, 1998; Worden, 1998). Therefore, it is suggested to offer the child appropriate psychotherapeutic care through strategies that favor the expression of grief reactions in the bereaved children (Andrade, 2013).

Accordingly, the present systematic review aimed to investigate, in national and international literature, the biopsychosocial factors involved in childhood grief resulting from the death of parents due to homicide, as well as the psychotherapeutic approaches applied to this situation.

 

2. Method

2.1 Material inclusion criteria

The material selected for the present study specifically consisted of articles regarding the grief of children between zero and 12 years of age due to the death by homicide of one or both parents, in order to analyze the biopsychosocial characteristics involved in child grief and the psychotherapeutic approaches applied to the referred context of loss.

As the source for the analysis, articles available in full in Portuguese and/or English were used, without delimitation of a period, in the American Psychological Association (PsycINFO), US National Library of Medicine National Institute of Health (PubMed), Biblioteca Virtual em Saúde Psicologia (BVS-Psi) and the Portal de Periódicos Capes. These databases were defined taking into account the content and covered of multidisciplinary studies, contemplating national and international productions, and the theoretical and methodological approaches, the targets of this study.

2.2 Documentary data collection procedures

Initially, searches were performed in the Thesaurus of Psychological Index Terms (Thesaurus), in the Medical Subject Headings of the US National Library of Medicine (MESH) and Descritores em Ciências da Saúde (DeCS) to identify the descriptors, which were defined together with the Boolean operators: "Griefs" OR "Mourning" OR "Mournings" OR "Grief" OR "Bereavements" OR "Bereavement" AND "Child" OR "Children" OR "Minors" OR "Development, Child" OR "Development, Infant" OR "Infant Development" OR "Child, Preschool" OR "Children, Preschool" OR "Preschool Child" OR "Preschool Children" OR "Child" OR "Infant" OR "Infancy" OR "Preschool Child" OR "Children, Preschool" OR "Preschool Children" AND "Homicides" OR "Murder" OR "Murders" OR "Killing" OR "Killings" OR "Homicide." The quotation mark feature was adopted to refine the searches. The "Advanced Search" option was used to narrow the search fields (titles, subjects, abstracts, and keywords). We selected articles in English and Portuguese, using the "language" filter, when available in the database. Exceptionally in the Portal de Periódicos Capes, the following filters were selected to fulfill the inclusion criteria: topic (child) and type of material (article). The final manual search was conducted by the authors in January 2019.

The search retrieved the following articles: 79 in the BVS-Psi, 39 in PubMed, 37 in the Portal de Periódicos Capes, and 3 in PsycINFO, totaling 158 articles. All of these articles (N = 158) were exported to an Excel spreadsheet. Then, 119 duplicate articles were excluded (i.e., the results that appeared in more than one database).

The remaining articles (n = 39) had their abstracts read, evaluated and subjected to the following inclusion criteria: 1. theme: grief; 2. population: children (0-12 years); 3. type of death: homicide; 4. victim(s): one or both parents; and 5. types of studies: quantitative, qualitative and/or mixed. Next, 22 articles were excluded, considering the exclusion criteria: 1. theoretical studies and systematic reviews; 2. posters, abstracts, dissertations/thesis and annals of events/congresses; and 3. population and type of death: distinct and/or heterogeneous.

The selected articles (n = 17) were then read in full. Of these, ten articles were excluded, considering the inclusion and exclusion criteria, for the following reasons: hybrid population (e.g., children and adolescents; children and adults), heterogeneous causes of death (e.g., homicide and suicide, homicide and "natural causes") and distinct family member (e.g., siblings). Accordingly, seven articles were selected to compose the qualitative analysis, which aimed to identify the concepts and methods for the analysis of the main aspects indicated in the studies.

The flowchart of the steps of the systematic evaluation process of the articles (Figure 2.2.1) shows the number of studies selected and eliminated in each of the steps of the systematic evaluation process, considering recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - PRISMA (Liberati et al., 2009). The mapping of the articles was conducted independently by the authors. It should be noted that there were no divergences during the analysis of the inclusion and exclusion criteria at each stage since all questions were previously debated and clarified by consensus among the authors.

 

 

2.3 Analysis procedures

Considering the objectives of the study and aiming for identification and systematization, the following categories were proposed for the qualitative analysis of the results: 1. objectives of the studies; 2. general aspects of the studies; 3. biopsychosocial characteristics of children resulted from parental death by homicide; and 4. psychotherapeutic approaches with the children in the context of the loss of parents due to homicide. The first category will seek to describe the aim of each study. The second category will help in the identification of the studies and methodologies they used. In the third category, the biological, psychological, and social aspects identified in the studies that may contribute to the psychological assessment and psychotherapeutic intervention will be identified. Finally, in the fourth category, the objectives, frequency, and techniques applied in the psychotherapeutic interventions directed toward the children and their respective family members will be analyzed. Furthermore, other relevant information and mechanisms of action suggested by the authors in the last two categories will be highlighted.

The present study was registered in the International Prospective Register of Systematic Reviews - PROSPERO database of the Center for Systematic Reviews and Dissemination at the University of York (England) under code: CRD42019120703.

 

3. Results

3.1 Objectives of the studies

Schonfeld, Shekunov, Jellinek, and Stein (2016) presented a case report of a nine-year-old girl who experienced grief due to the death of her mother that was a homicide victim after a robbery in a convenience store. The article highlighted the main considerations about the case, suggesting, in the end, possible care strategies for the child.

Zeanah and Burk (1984) reported the case of a four-year-old girl who witnessed the homicide of her mother by her father. The authors also reviewed the legal literature, emphasizing the importance of investigating the children's mental health status to better assess her obligation to testify when requested by the criminal justice system. This work aimed to raise awareness among mental health professionals, the wider community, and the criminal justice system regarding the need to treat children who witnessed a parental homicide.

Black, Harris-Hendriks, and Kaplan (1992) formulated some basic principles for professional practice from an experience with more than 100 children whose fathers perpetrated their mothers' homicide. From this, six case reports of children were presented, four girls (between three and six years of age) and two boys (five and six years of age), who witnessed the death of their mothers, aiming to reinforce the need for a brief evaluation and intervention by a team specialized in this context of loss.

Burman and Allen-Meares (1994) used an analysis of the case report of two brothers, four and eight years of age, who witnessed the homicide of their mother by their father. This report allowed the observation of some symptoms, such as aggression, withdrawal and nocturnal enuresis, and the indication of theoretical references regarding psychosocial development (Erikson, 1968) and social learning (Bandura & Walters, 1963) to guide the professional intervention. The authors also presented behavioral and expressive strategies of therapeutic treatment and family intervention practices that may favor the improvement of the quality of life of bereaved children in the context of traumatic parental loss.

Schetky (1978) analyzed case reports between two pairs of siblings (boy and girl), two and four years of age, who witnessed the homicide of their mothers by their fathers and discussed some of the variables that influence the grief due to traumatic loss. Rupa, Hirisave, and Srinath (2013) described the psychotherapeutic process of a boy, seven years of age, in the custody of his maternal grandmother and great-grandmother, following the testimony of the homicide of his mother by his father. To this end, they indicate characteristics, techniques, and strategies, as well as the therapeutic gains achieved in this case.

From his professional experience in a clinic focused on childcare after uxoricide cases, Black (1998) described the work done with a boy, four years of age, who witnessed his mother's homicide while his other two brothers were at school. Similarly, from the case of three brothers under five, the author highlighted the experience of a boy, three years of age, who had also witnessed his mother's homicide. This work aimed to highlight some aspects that involve the traumatic loss of a parent and the need for therapeutic intervention for these children.

3.2 General aspects of the studies

As mentioned, the search in the databases presented a total of seven articles, among which four were from PubMed and three from BVS-Psi. All the articles were published in English, three being from the United States, three from the United Kingdom, and one from India. It is evident the absence of Brazilian studies in this study. The studies retrieved were published between 1978 and 2016. Of these, five were developed in the 1990s and only two after 2000.

It was also observed that two of the articles were published in journals focused on pediatric health, these being the Journal of Developmental & Behavioral Pediatrics and the Indian Journal of Pediatrics; two other articles were published in journals of psychotherapy practice and research, the American Journal of Psychotherapy and Psychotherapy and Psychosomatics; one article was published in a journal focused on social work, Social Work; and the other two in psychiatry journals, the Bulletin of the American Academy of Psychiatry and the Law and the International Journal of Psychiatry in Clinical Practice.

Regarding the methodological design, all the articles found were qualitative through a clinical case study of 17 children aged between two and nine years, including eight girls aged between two and nine years and nine boys aged between two and eight years. Among these children, 16 witnessed the death of their mother, who was the victim of homicide perpetrated by the father.

The general aspects of the studies (Table 3.2.1) represent the synthesis of each of the seven articles, through the following categories: 1. article title (author/year); 2. database; 3. language; 4. journal; 5. type of study; 6. country; and 7. participants.

 

 

3.3 Biopsychosocial characteristics of children resulting from parental death by homicide

Among the studies that are part of this literature review, Zeanah and Burk (1984) presented the report of a child living in a family context permeated by strife between the parents and psychiatric hospitalizations of the mother due to impulsive episodes, outbursts of anger, suicide attempts, drug abuse, and brief psychotic episodes. The child lived temporarily with guardians (mother's cousin and husband), with whom her development proceeded without difficulty. However, after returning to the parental home, the child witnessed the mother's homicide perpetrated by the father. Based on the child's testimony about the violent scene she witnessed, the father was arrested, and the child was returned to the guardians. In later weeks, the girl experienced a variety of emotional and behavioral reactions, including hyperactivity, anxiety, fear of going to the bathroom alone, sleep disturbance, preoccupation with danger, nocturnal enuresis, distortions of the traumatic experience, and feelings of anger and guilt due to the impossibility of averting the death of her mother.

Given the above, the authors stated that the therapeutic treatment involved a complex and conflicting scenario. They also stressed the importance of promoting the relief of suffering and symptoms, attention to cognitive aspects of the child, and the establishment of a healthy environment for the child's development. Accordingly, the authors believe that the risks of future problems arising from the traumatic experience can be minimized.

In the study by Schonfeld et al. (2016), the child, aged nine years, lived with her mother, and did not know her father. Though tired after a hard day's work, at the child's request, the mother went out to buy food for the pet cat, however, was fatally shot in the parking lot of a convenience store. On the same day, the girl's uncle and aunt took her, abruptly and without explanation, to their home in another state, without the child being able to fetch her personal belongings, say goodbye to friends at school or attend her mother's funeral. The girl had trouble adjusting to her uncle and aunt's family routine, where there were two other children, expressing a feeling of being treated like a baby. Despite their sympathy, the uncle and aunt felt they needed more structure to support their niece after the traumatic loss of her mother, so they sought medical help and parental counseling. The authors mainly highlighted the expression of the girl's feeling of guilt (due to the request made to the mother), as well as the direct influence of the changes after the loss of her mother (e.g., funeral ceremonies, change of residence and school) on the development and grief processes, these being the main focuses for the care for the child (Schonfeld et al., 2016).

Schetky (1978), in his study as mentioned earlier, observed distinct grief reactions: fear of loud noises, questions about the causes of death, feelings of inadequacy, obscene language, impulsive behaviors, mood instability, and concerns about the future. The author emphasized the influence of the litigious environment concerning the custody of children and recommended the brief resolution of the judicial process aiming to provide a safe environment for the physical and emotional needs and the expression of the child's grief.

Rupa et al. (2013) highlighted the expression of vulgar vocabulary, aggression against other children and family members, and frequent reactions of anger among the main complaints presented by a boy, seven years of age. The authors emphasized the deleterious impacts of domestic violence during the child's life trajectory and the possible damage to the child's health and, consequently, in the expression of grief from the judicial testimony about the mother's homicide.

Black et al. (1992) found that children that lost their mothers to homicide by their fathers were more likely to develop PTSD and other psychiatric problems. The authors indicated that these children commonly have low self-esteem due to the context of family loss, the harmful influence regarding the omission of information about changes after the loss (e.g., place of residence) and the inability to attend funeral ceremonies, factors that directly influence the process of childhood grief. In another study, Black (1998) identified a greater likelihood of reality dissociations, PTSD, and disorder of attachment driven by frequent changes in caregivers. In the article, the author analyzed the reflection of the family dynamics in the grief process of the children attended.

Finally, Burman and Allen-Meares (1994) noticed differences between the expressions of the grief of two brothers. For example, while one was aggressive, even inclined to an obsessive fascination with guns (an eight-year-old boy), the other (four years of age) was withdrawn and presented nocturnal enuresis. However, the authors noted two common characteristics between the siblings: a drop in school performance and difficulty in interpersonal relationships. In the family environment and the context of the social insertion of the family, Burman and Allen-Meares (1994) highlighted family violence, in the society as a whole, the absence or precariousness of the support network and, in the family life, socioeconomic factors (e.g., racial prejudice and unemployment) as elements that directly influenced the experience of childhood grief.

3.4 Psychotherapeutic approaches with children in the context of parental loss due to homicide

In the study by Schonfeld et al. (2016), the need was stressed for a brief intervention, judging the impact of the grief on the psychological functioning, emotional adjustment, health, and developmental trajectory of the child considering this significant loss. Accordingly, they highlighted the importance of the child's participation in the funeral ceremonies preceded by dialogue, attention to the losses and secondary stressors (e.g., trauma associated with witnessing the homicide and relocation), and the school's assistance during the grieving process through prior preparation of the team. The authors recommend using a "memory box" containing objects and photos of the deceased family member during the intervention with the child, which makes it possible to relive the memories, facilitate the dialogue and provide the experience of grief. In the end, Schonfeld et al. (2016) suggest continuous care from healthcare professionals for the bereaved children, to monitor the effects of the traumatic experience and to avoid possible deleterious manifestations to their health (e.g., depression and anxiety).

In the study by Zeanah and Burk (1984), the following therapeutic goals were highlighted: the relief of symptoms related to the grief, the restoration of psychological balance for the resumption of age-related tasks, and the reduction of risks of psychological problems due to the trauma. To this end, they conducted a thorough anamnesis interview and guided tutors about childhood grief. They sought to establish a relationship of trust with the child to address the issues related to the death and bereavement, including the feeling of guilt and performed role-play regarding the traumatic event to relieve symptoms related to PTSD. Finally, Zeanah and Burk (1984) suggested that healthcare professionals, the community, and the criminal justice system offer appropriate care to bereaved children in the context of traumatic and violent loss.

Black et al. (1992) indicated the need for immediate interventions (soon after the homicide) developed by a team specialized in traumatic events with children focused on their physical and mental health. The authors also consider warning primary healthcare services about the health of the children, as well as immediate consultations, focused on assessing mental health status. In the long-term, the authors cited the need for attention to judicial issues (e.g., inheritance, custody and visitation), which should be guided by the principle of the best interests of the child, and assessment of when the child should testify in court. They also emphasized the effectiveness of the counseling practice in dealing with childhood bereavement issues, as well as the providing guidance and support to caregivers in their own and the children's grief. Black et al. (1992) highlighted the importance of developing long-term studies to assess what happens to children when the father - who perpetrated the homicide - returns to socializing and when the children grow up, besides studies on different forms of treatment.

Burman and Allen-Meares (1994) reported the development of individual and group psychotherapeutic sessions and semi-structured interviews in order to comprehend the biopsychosocial characteristics of children, the relationship established with the deceased family member, the family context, the circumstances of the loss, the support received and the surroundings (e.g., society and culture). The authors indicated the effectiveness of the postulations of Erikson (1968) about psychosocial development and Bandura and Walters (1963) regarding social learning since they certainly contributed to the psychotherapeutic intervention with bereaved children in the context of violence. Non-verbal communication techniques (e.g., arts, drawings, games, storytelling, and photographs) and techniques based on the cognitive-behavioral approach (e.g., co-therapy, self-control strategies for anger management, and social skills training) were used during the sessions, with clinical and school observation of the children also being carried out. Regarding the counseling, the authors encouraged the brothers to practice sports in order to foster the development of social skills and the formation of new bonds, as well as the participation of family members in support groups to help cope with their grief and the bereavement of the children. In the end, Burman and Allen-Meares (1994) emphasized the importance of interdisciplinary work and the need for studies that address bio psychosocial issues and intensive care for bereaved children in the context of violence.

Schetky's (1978) work indicated the need to provide care for the surrogate parents in not only establishing an environment of security and trust, but also ensuring true dialogue about the facts according to the stage of cognitive development of the child. The author emphasized the importance of establishing a solid support network for the child (e.g., school and other family members) and adopting a cautious stance regarding the child's involvement in court proceedings, as well as the child's contact with the parent that perpetrated the crime. Finally, Schetky (1978) recommended the development of studies to better evaluate and treat these issues.

Regarding the frequency of the sessions with the bereaved children in the above conditions, Rupa et al. (2013) explained that this should be defined according to the specificities of each case. In a work developed by the authors, daily sessions were held for three months, followed by weekly and subsequent bimonthly sessions. Playful sessions were performed through individualized techniques (e.g., music, storytelling, and varying role play), and debates on the concepts of irreversibility and inevitability of death helped progressively advance the expression of the child's grief. The authors found that, for the success of a psychotherapeutic intervention, it was necessary to adopt a non-directive, receptive and supportive posture, as this contributed to the assertive communication and emotional maturity of the bereaved children (Rupa et al., 2013).

Black (1998) recommended the need for a brief child assessment by staff with experience in caring for children bereaved due to traumatic loss and the development of interventions to reduce/prevent PTSD related symptoms. According to the author, the realization of therapy aimed at promoting the expression of childhood bereavement should include the debate about funeral ceremonies and the concepts of irreversibility and cessation of bodily functions, as well as various psychological techniques that help to process the traumatic issues. The author emphasized the importance of providing appropriate advice to the Justice Tribunals and Social Work teams about the possibility of contact between the parent who perpetrated the homicide and the child.

 

4. Discussion

In the present systematic literature review, it was found that the production of articles on child grief due to the death of parents that are victims of homicide is still restricted in the international and, above all, national scenarios. Even so, the sample of seven qualitative articles highlights the specifics of children's grieving in this context of loss (Black, 1998; Black et al., 1992; Burman & Allen-Meares, 1994; Rupa et al., 2013; Schetky, 1978; Schonfeld et al., 2016; Zeanah & Burk, 1984).

Grief is a complex and multidimensional phenomenon in which the process and consequences are influenced by the interaction of a series of physical, psychological, and social components (Silva & Ferreira-Alves, 2012). Each subject will confront the reality of death in their way (Kovács, 2003). It was possible to observe among the selected studies symptoms of fear, anger, anxiety, and guilt, nocturnal enuresis, aggressive behavior, the occurrence of dissociation from reality, attachment disorders, and symptoms related to PTSD when the children witnessed the homicide.

To initiate the therapeutic care of the child, the immediate psychological assessment process was recommended to investigate cognitive, physical, behavioral, and emotional symptoms (Black, 1998; Black et al., 1992). The following treatments were also suggested to assist in the grieving process: psychotherapeutic interventions focused on relieving grief-related symptoms (Zeanah & Burk, 1984), attention to the losses and secondary stressors (e.g., relocation) (Schonfeld et al., 2016), the promotion of debates on the concepts of irreversibility and inevitability of death to help progressively advance the expression of the childhood grief (Rupa et al., 2013), and the establishment of a solid child support network (e.g., school and other family members) (Schetky, 1978), among others.

It should be noted that, among the studies that composed the sample, the majority (n = 6) considered the bereavement of children that witnessed cases of uxoricide. In this context, it was evidenced that the damage to the well-being and quality of life of the children with a history of intrafamily violence was multiple (Black, 1998). Likewise, the absence of a close emotional relationship between children and parents in the family context, associated with inadequate stimuli and the presence of domestic violence caused developmental damage (Silva, Maftum, & Mazza, 2014), which may affect the cognitive, emotional, behavioral and social spheres, possibly promoting deleterious effects throughout adulthood (Reichenheim, Hasselmann, & Moraes, 1999). Among these effects, learning difficulties, mood instability, expression of behaviors associated with depression, and problems in interpersonal relationships were reported (Abranches & Assis, 2011). Other consequences mentioned include changes in the central nervous system and cognitive functions (Silva et al., 2014). For intervention directed toward these occurrences, therapeutic care regarding the issues related to grief and the reflection on family dynamics in the grieving process of the children attended was recommended (Black, 1998; Rupa et al., 2013). Stands out the importance of long-term studies to investigate what happens to children when the father, who perpetrated the homicide, returns to conviviality and when the children grow up, besides studies about different forms of treatment (Black et al., 1992).

After the death of a beloved adult person, the child experiences intense pain reactions and denial of the loss in the face of grieving processes (Bowlby, 1993). These reactions can be aggravated in the circumstances of grief resulting from violent death (Parkes, 1998; Worden, 1998). In this context, immediate intervention is suggested, including psychological assessments (Black, 1998; Black et al., 1992) through different fundamental sources (e.g., psychological instruments) and complementary (e.g., multidisciplinary reports) for obtaining information (Conselho Federal de Psicologia, 2018). Also, sequential psychotherapeutic care is recommended to contribute to the children's grieving experience and quality of life (Parkes, 1998).

Accordingly, the relevance can be noted of adopting a theoretical approach that contemplates human development and the complexity of the phenomenon of grief, aiming to cover both the individual and contextual components associated with the loss, thus providing appropriate care for the needs of the bereaved child (Burman & Allen-Meares, 1994). Also, the use of nonverbal communication techniques (e.g., music, drawings, and storytelling) was observed, as these enable the expression of grief reactions that permeate children's behaviors. As a proposal for clinical management, the techniques as mentioned earlier, and theoretical approach can contribute to the expression of emotions and thoughts, enabling the experience of grief and construction of meaning in the face of loss (Burman & Allen-Meares, 1994; Mazorra, 2009; McIntyre & Hogwood, 2006).

As exposed in the present investigation, the data found refers to international studies, demonstrating the limited national production on the subject. Regarding this fact, Soares, Miranda, and Borges (2006) consider that statistical data on the growth of violence, particularly homicides in the city of Rio de Janeiro, has been released by public institutions over the years. However, the authors draw attention to gaps in the national literature regarding surviving victims, including children, after the death of family members due to homicide. Soares et al. (2006) indicate the use of international sources to guide Brazilian studies. However, they emphasize the importance of adopting caution in the interpretation of these results, since socioeconomic and cultural factors directly influence the investigation of the phenomenon of violence. The authors suggest the developing of studies involving professionals from different areas in Brazilian society, including children and their idiosyncrasies.

Besides, we consider the hypothesis that the lack of studies concerning exclusively to the population object of the present investigation (i.e., child grief between zero and 12 years of age) occurs due to specific ethical aspects involved in this type of analysis. These particularities concern, for example, the avoidance of further weakening or psychological harm to the participants (Cook, 2001), approval in ethics and research committees of higher education institutions, and the authorization of legal guardians via Informed Consent Term (IC), and the request for the involvement of experienced multidisciplinary professionals that are sensitive to the circumstance of death (Soares et al., 2006); understanding aspects of human development and the complexity of the grief phenomenon (Burman & Allen-Meares, 1994); understanding family aspects and their background (e.g., the occurrence of intrafamily violence) by the professionals (Black, 1998; Silva et al., 2014); the use of reliable instruments for children's audience (Soares et al., 2006); and attention to the characteristics of vulnerability and the psychological structure of bereaved people (Parkes, 1995), in this case, children, among other aspects.

Therefore, the importance is ratified of new studies that explore the unique questions and experiences related to death and the phenomenon of bereavement with children, especially in the context of homicides, in a way that reverberates in their families and the community as a whole (Eth & Pynoos, 1994; Gonzaga & Peres, 2017). From this angle, the use of mixed research methods would make it possible to carry out studies with different methodological designs, but produce mutually complementary data, favoring a broader assessment of the investigated phenomenon (Santos et al., 2017). Considering the specificities in the context of loss regarding biopsychosocial characteristics, longitudinal studies could be effective in ensuring the elaboration of deeper knowledge on the subject. Likewise, these would make it possible to raise more functional prognoses, demonstrating over time the unfolding of the childhood bereavement process (Black et al., 1992) and contributing to the adjustment to loss (Parkes, 1998; Tinoco, 2007).

For this, it is indispensable for psychologists to explore the issues surrounding death and to be aware of the individual and contextual factors that influence the grieving process (Burman & Allen-Meares, 1994; Worden, 1998). It is also essential that they use theoretical frameworks, develop technical skills and carry out robust scientific productions, considering the epistemological and operative aspects of quantitative and qualitative approaches (Santos et al., 2017). With this, it is believed that it is possible to contribute considerably to the advancement of the evaluative and psychotherapeutic processes for the quality of life of bereaved children.

 

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Correspondence:
Karolline de Jesus Saraiva Menezes
Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio), Departamento de Psicologia
Rua Marquês de São Vicente, 225 (Ed. Cardeal Leme), 2º andar, Gávea
Rio de Janeiro, RJ, Brazil. CEP 22451-900, Caixa Postal 22470-060
E-mail: karolline.saraiva@gmail.com

Submission: 08/04/2019
Acceptance: 26/11/2019

 

 

Authors notes
Karolline de Jesus Saraiva Menezes, Postgraduate Program in Psychology, Pontifical Catholic University of Rio de Janeiro (PUC-Rio); Juliane Callegaro Borsa, Postgraduate Program in Psychology, Pontifical Catholic University of Rio de Janeiro (PUC-Rio). This study was supported by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes) through the provision of a Master's scholarship to the first author.