Center for the Study of Traumatic Stress
CSTS | Department of Psychiatry | Uniformed Services University | 4301 Jones Bridge Road, Bethesda, MD 20814-4799 | www.CSTSonline.org

Caring for Children After
Parental Death:
Guidelines for Primary Care Providers
Approximately 3% of children
complaining of somaticPrimarycare
providersareimportantpoints
experience the death of a parent
symptoms that may be related
from illnesses, accidents, disasters,
to grief rather than to a physicalof contact and support for children after
suicide, and interpersonal violence.
health condition. Examples
parental loss.
Primary care providers,
include fatigue, loss of appetite,including pediatricians, family
nausea, headache, chest
physicians, and nurse practitioners,
pain, and insomnia, as well
are important points of contact and support for children
as aggression, social isolation, or reverting to earlier
after parental loss. Bereaved children visit these providers
childhood behaviors.

Parental loss is often traumatic for children. Primarycare providers should be familiar with “The Four R’s ofTrauma-Informed Care” described by the Substance Abuse
and Mental Health Services Administration (SAMHSA;
www.samhsa.gov):■ Realize the widespread impact of trauma andunderstand potential paths for recovery■ Recognize the signs and symptoms of trauma■ Respond by fully integrating knowledge about trauma
into practice■ Resist re-traumatizing children, as well as theircaregivers, by unnecessarily exposing them to additional
traumatic information
Developmental Considerations■ Ages < 6: Younger children engage using creative outlets(e.g., painting, drawing, and comic books) offering
concrete images and addressing loss in stories orpictures, rather than direct conversations about death■ Ages 6-12: School-aged children are often able to use
language to communicate how the loss affects them andtheir families as they are developmentally transitioning
away from concrete thinking■ Ages 13+: Teenagers are more capable of using language
to discuss thoughts and feelings about parental death,and can use abstract thinking to understand its meaning

Guide to Open Communication
Healthcare professionals should establish a positive
rapport with children and facilitate open communication
about loss using developmentally appropriate language thatis unambiguous (e.g., use specific terms, such as “death,”rather than “passed away” or “gone”).
■ Ask: Use open-ended questions to create a comfortableenvironment for a child to initiate their narrative (e.g.,“I am so sorry about the death of your mother. I know
this must be very hard. Can you tell me how you aredoing?”)■ Listen: Reflect on a child’s story to gather pertinentdetails, non-verbal cues of emotional distress, and issues
that require further cognitive processing■ Respect: Avoid overly simplistic explanations(e.g., “Things happen for a reason.”) and unhelpfulrecommendations (e.g., “You need to move on.”) thatminimize a child’s painful loss
■ Repeat: Incorporate a child’s language to inquire
about missing details or confusing timelines to avoid
misinterpretations (e.g., “So, when you say your father
had ‘some sort of accident’ it sounds like you havequestions about what happened.”)■ Record: Write down the child’s narrative as a reference
for future visits
Continued

Support Surviving Caregivers■ Acknowledge the challenge of parenting while
grieving (e.g., single parenting at a time of distress)■ Refer grieving parents to their own helpful griefsupport services in their community■ Encourage grieving parents to seek assistance fromfriends and family members■ Discuss opportunities for respite childcare■ Help parents understand that they are importantmodels to their children in managing their own grief■ Provide information about trustworthy online
resources that address childhood grief (www.nctsn.
org, www.aacap.org, www.aap.org)
Assess for Trauma or Grief-Related Conditions
Healthcare providers should be aware of signs andsymptoms that indicate a child has a clinical condition
that requires grief- or trauma-focused treatment.
Practitioners should be prepared to refer children toevidence-based treatments (e.g., Trauma-Focused
Cognitive Behavioral Therapy [TF-CBT]: www.tfcbt.org)
as needed. Indicators of risk include prolonged or severereactions, such as:■ Intense sorrow, pain, and rumination over the loss
■ Focus on little else but the loved one’s death■ Extreme focus on reminders of the loved one orexcessive avoidance of reminders■ Intense and persistent longing for the deceased■ Problems accepting the death■ Numbness or detachment■ Bitterness about the loss
■ Feeling that life holds no meaning or purpose■ Lack of trust in others■ Inability to enjoy life or think back on positive
experiences with the loved one■ Loss of age-appropriate self-care behaviors■ Sleep disturbances (e.g., insomnia, nightmares)

Recommended Children’s Books to Help with Copingwith Grief■ No Matter What by Debi Gliori■ Everett Anderson’s Goodbye by Lucille Clifton■ Home Now by Leslie Beake■ The Sound of the Sea by Jacqueline Harvey

Center for the Study of Traumatic StressDepartment of Psychiatry
Uniformed Services University4301 Jones Bridge Road, Bethesda, MD 20814-4799
www.CSTSonline.org