BEREAVEMENT AND MENTAL HEALTH ISSUES FOR INSTITUTIONALIZED CHILDREN

The loss of a caregiver or loved one is a tragic moment, which can have psychosocial impact on a child. Children inside institutions either in foster or residential care are prevalence to the experience of neglect and parental loss bereavement. Bereavement endures a variety of factors that influence negatively on child mental health. The purpose of this concept paper is to explain noteworthy contributions with regards to information on bereavement among children and their psychosocial problems in institutions and residential cares. The attachment theory is significant to explain the association of bereavement and institutions, which supported the evidence that bereavement among vulnerable population inside institution, are at high risk of social deterioration. The theory implies a cause-effect relationship between early attachments. Children are potentially psychologically affected by any

traumatic events, which caused them to experience prolong mental developmental delay that are associated with different psychological disorders. Institutionalized children can easily become victim of their psychosocial inability to defend themselves from ruthless violence. Research had examined the differentiating factors of certain symptoms in normal grief and bereavement within the context of depressive disorders, including self-guiltiness, death thoughts, maltreatment, and worthlessness. Experiences of bereavement may occur over the loss, which then shifted to transient withdrawal. Parental loss is one of the most extreme social deprivations that a child can experience Therefore responses to parental loss may be age-specific, related to temperament and to culture. The literature indicated that bereavement in institutional settings has the potential to cause significant risks of mental health with the most prevalent impact related to psychological issues. To cope with the consequences of child maltreatment, prolonged effective interventions should be encouraged. Noteworthy, studies related to bereavement and stress to explain the psychological health issues of children due to parental loss in institutional care are limited, especially within the context of developing countries.

INTRODUCTION
Literally the term bereavement means 'to be robbed' or 'deprived of something valuable'. In our society it commonly refers to the death of a significant person. In other words, the term bereavement refers to the reaction of grief related to losing of loved ones. Research had revealed that the influence of bereavement on institutionalized children was related to environmental factors associated with children's mental health in terms of life events. Such complications were responses towards family conflicts, parental psychopathology, deprivation or separation, parental divorce, sexual and physical abuse and especially the parental death (Bhat, Rahman, & Bhat, 2015;Jesse & Dayle, 2013). Thus it can be construed that some experiences of bereavement are very complex, whether in terms of intensity, duration or timespan, or the inability of an individual to satisfactorily re-engage himself or herself into social and affective life (Revet, Benvegnu, Suc, Mesquida & Raynaud, 2020).
Psychiatric workup through multiple diagnoses acknowledged that children's developmental delay and poor appetites were due to chronic bereavement, poverty, parental rejection and maternal psychopathology (Dopp & Cain, 2012;Johnson & Gunnar, 2011). Additionally, it has been determined that maltreated children in residential treatment with experience of bereavement and traumatic loss associated with disasters consistently reported having 'Post Traumatic Stress Disorder; (PTSD) (Dopp & Cain, 2012;Fairbank & Fairbank, 2009). Bereavement is an excellent model of relevance to the attachment theory within the contexts of psychopathology and human functioning (Paterson & Moran, 1988).
Multiple variables of bereavement process can lead to complicated adjustment problems. The experience of loss at an early age may resulted in compulsive self-trust or anxious attachment as suggested by the maladaptive model of attachment (Paterson & Moran, 1988). Separation determines an instant precipitating stress in adults that leads to depression if object loss occurred during childhood. Coherently, the bereavement can stimulate the exertions of depression in the adults life (Moss & Moss, 2012;Lewis & Miller, 1990;300).
Despite the fact that separation is more stressful, discontinuation of care giving and tenderness of selective attachments is detrimental for the institutionalized children (Nader, 2008;182). The experience of "Losing an irreplaceable loved one through death (bereavement); reacting to loss in brokenness and sorrow (suffering); and responding to loss and suffering" (Judith & Thomas, 2015; 10) is an unbearable process to these children.
Young children may face the bereavement within an immense range of severe life events. Usually, the children aged between 5 to 16 years have drastic experience of parental and siblings' death (Akerman & Statham, 2014). Notably, bereavement, mourning, and grief may be influenced by culture, religion, personality, and the essence of a relationship with the dead person. In this sense, bereavement is defined as the response towards loss, which triggers the reaction of grief that is recognised as mourning (Buglass, 2010).

Childhood Bereavement
The literature sustained the association between child adjustment and parental bereavement. This association involves the strength to build close relationships and primary developmental domains, as well as to diverse consequences of trauma and stress (Dopp & Cain, 2012). It is very difficult for adolescents to share or talk about their childhood complex bereavement (Rolls & Relf, 2006).
The death of a parent is a stressful situation for children. At this time the children are very much in need of support, but the opposite can happen due to changes in the family and the role of the family during post bereavement. In some cases, the parent or carer of the child is also struggling with grief and is likely to experience psychological difficulties. As a result, it is a big challenge for this parent or carer to provide adequate support to the child. Sometimes, the living parent has to deal with and cope with the additional stressors of being a single parent and sole provider, and at the same time coping with the issue (Bergman et al., 2017).
Children may experience numbness, shock, and may feel upset to deviate from the nervousness and sadness, and may exhibit apparent distress as a result of encountering bereavement caused by the deceased of loved one, the loss of possessions, and safety (Williams, 2006). Parental bereavement in children may potentially render them to psychopathology and adjustment difficulties as opposed to the case of non-bereaved children. Following of parental death, the children may be exposed to increased fear, aggression, somatisation, depression, psychoneurotic symptoms, academic problems, and developmental delay (Dopp & Cain, 2012). Bowlby's (1989) asserted that parental death may cause symptoms of separation anxiety in orphaned children due to secured attachment formerly formed with their parents. The literature had provided evidence that there is no vital difference in the anxiety score between neglected and double orphaned children. Trauma theorists inferred that violent or complicated bereavement may bring about the tendency towards Post Traumatic Stress Disorder (PTSD).
Clinicians have identified the occurrence of sensitizing impression of stress experience. They suggests that following bereavement, an individual who suffered from the death of loved one is vulnerable to psychopathological impact later in life (Rutter, Scott, Stevenson, & Taylor, 2008: 397). Bereavement may occur in various forms depending on the child's age. It has been recognized that death is a significant factor of distress while normal bereavement is not recognized as the risk factor in diagnosis of PTSD.
It has been observed that trauma symptoms among adults are more complicated in contrast to the children's traumatic grief. In addition, death witnessing, or body discovering, recognition of traumatic death may be adequate episodes of traumatic grief (Nader, 2008: 249). The bereavement of accidents and illness may derive from unexpected, sudden, mutilating or violent deaths, especially witnessed by the child, of their family members may cause a more severe psychopathology (Rutter et al., 2008: 399).
Bowlby's studies proved the long lasting effects of bereavement and separation in childhood. He was convinced that psychiatric disability of adults can be ascertained back to their trauma history (Homes, 1993). Bereavement is a particular type of life stress and has been given a distinctive recognition of stress reaction. Bereavement is excluded from DSM-IV psychiatric disorders as these are normal reactions. Pathological grief reactions, considered as disorders, are more related to adults than children. Bereavement reactions have different forms and have never been excluded from ICD-10 (Rutter et al., 2008: 398).
Children suffered negatively from bereavement and even the grownups could never understand death. Not many studied focuses on children's emotions (Kazim & Mohamed, 2016). "Loss of a parent can lead to adverse consequences. A positive relationship between the parents prior to the death and a strong surviving parent to keep the family intact have been identified as protective against elevated risk of mental health problem. Among the predictors of complicated bereavement are prior child emotional difficulties, emotional labiality and poor impulse control" (Rutter et al., 2008: 952).
Bowlby observed that grief reaction is a distinctive example of separation anxiety and bereavement is a constant reaction resulted from separation (Homes, 1993). Child safety is comprehended and assured as the positive enduring bond expressions that form the focus of parental bereavement. Negative bond expressions will live within the children who blame their parents with regards to their protection, and experiencing the intense guilt of living with the inadequate caregiver (Field, Gao, & Paderna, 2005).
Childhood loss can be seen to have long-term effects. Childhood bereavement is a significant factor in adult's depression. Nevertheless, findings from research are contradictory on this point. Vulnerability and inadequate care are the prominent factors of depression and the presence of vulnerabilities contributed as the additive effects of loss in the adult's life that made him becomes more depressed (Homes, 1993;180).
Findings of previous studies have also found that loss affects PTSD and depression. Recent research on depression found that bereavement is the most significant predictor for depression in post disasters. Research on youth who were trauma survivors (absence of death) and bereaved survivors had reported increased rate of PTSD symptoms, depression, arousal and worry (Dyregrov, Salloum, Kristensen, & Dyregrov, 2015).
Interventions, even if occurring in a short period of time, can prevent the child from experiencing more severe problems after the loss of his or her parent such as traumatic grief and mental health problems. In fact, studies have shown that interventions have a positive effect on both the children and caregivers (Bergman et al., 2017).

Role of Attachment Theory in Child Bereavement
Bowlby (1980) emphasizes on healthy attachment relationships of institutionalized children with their caregivers or educators. This theory counselled the development of children and their early attachment interactions towards later social development (Bettmann, Mortensen, & Akuoko, 2015). Bowlby (1982) also postulated the different phases in the grieving process of human life (Li et al., 2008). Bowlby's work had contributed enormously and remains relevant till the present day. According to the Children Act 1989, it is anticipated that care in foster homes is internationally accepted and is preferable than group care (Homes, 1993). Bereavement referred to psychiatric complications in parenting styles and attachment patterns in childhood are related to the attachment patterns later in adulthood (Stroebe, Schut, & Stroebe, 2005). Apparently, it is acceptable that the theory underpinning most impactful research on bereavement is Bowlby's attachment theory. Bowlby's work on grief is the resolution for rearranging representations of lost person and its important relation to the self (Schut, Margaret Stroebe, 1999).
According to Bowlby, loss of a partner is the early phase of the origin of bereavement, which is referred as the reorganization stage. Interestingly, the term detachment was initially introduced in bereavement. The death of parents, either one or both, has a serious lifelong effect on the children psychological well-being. Due to the emotional dependency and developmental vulnerability, adolescents are left with a particular risk of being in a complicated and unresolved bereavement (Buglass, 2010;Getachew, Ambaw, Abebe, & Kasahun, 2011).
Avoidant of attachment and experiencing persistent difficulties may result in the expression of grief. During bereavement, the lack of trust coupled with a disorganized attachment, may resulted in high scores of depression, panic/anxiety, and substance used (Stroebe et al., 2005) when assessed. Bowlby had relied and explained on the experiences of childhood bereavement and the reactions following it during adulthood. He explained that attachment phenomena and was certain that mutual relationship, which transpired as a result of longterm synergy, started from infancy between child and his parents, and follows him to adulthood. Such association is indeed strong and significant, and prevailed throughout life (Buglass, 2010).
On another scenario, parent's death affects the child's education severely. Young children going through this adverse situation may plunge more and more into profound levels of depression as they older. When this situation arises, community's support is significance. As exerted by Sengendo and Nambi (1997), community guidance for such children is vital to help them cope with early bereavement.

Child Mental Health in Bereavement
Bereavement complications are labelled as conventional psychiatric type of critical stressor in children that triggered the mental and physical disorders in them, which include posttraumatic stress disorder, major depression, sleep disorders, and anxiety. These co-morbidities demand that clinical attention, identification, and treatment are provided to the children (Hall, 2014).
Research that examined the situations of childhood bereavement had been carried out in the past and reported that children acquired extensive experience towards grief. Based on their behavioural and emotional responses, their experience was classified as nonspecific disruption. These responses included depressive symptoms, angry outbursts, regression, fears, and anxiety with regards to developmental breakthrough, self-esteem and eminent outer locus of control (Haine, Ayers, Sandler, & Wolchik, 2008). Nsabimana et al. (2019;p. 9), "… suggests that not being able to live with the own parents, regardless of whether they are dead or alive, seems to impair children's self-esteem more than living in an institution or not".
Recognizing the emotional agitation that is inherent for psychological disorder and instinctive to parental bereavement, peer support is known could help by playing a guarding function to enhance the child's adjustment. Bereavement may weaken or eradicate the sources of peer support and oppose their guarding functions and created additional stressors. However, the importance of peer's role, influence and support of various factors remained absent in the literature of child bereavement. Empirical investigation also contributed as potential resources for enhancement of the protective intervention designs to diminish the negative outcomes later in the child's life (Dopp & Cain, 2012).
Studies about death of the loved ones had found the dominant depressive symptoms in adolescents from 11-16 years children (Akerman & Statham, 2014;Cacciatore & Flint, 2012). The peers' attachment in institutions had acute and chronic bereavement implications on children. The psychosocial support to orphan and vulnerable children will need to adequately deal with the status of attachment and mental health within a developmental framework inside institutions (Trickey & Nugus, 2011;Blower, Addo, Hodgson, Lamington, & Towlson, 2004).
Nevertheless, beside the negative outcomes, some studies had reported the positive psychological alteration through ethnographic study on child bereavement with the experiences of parental bereavement. The outcomes include matters related to gratitude, appreciation, altruism and desire to gain pleasure by interpersonal coping, which helped improve the child's development of interests and personal strengths after some years of parental death (Balk, 1996;Akerman & Statham, 2014).

Institutionalized Bereaved Children
Being in child care institutions for a long time affects the psychosocial aspects of a child. This was apparent within the psychological and sociological oriented research carried out in Indian child care institutions which concluded that prolonged institutionalization and parental deprivation damaged the mental ability and personality of children. They become less thoughtful, less ambitious, more fearful and less susceptible to shame and guilt (Judith & Thomas, 2015;Trickey & Nugus, 2011;Blower et al., 2004).
Another example is the study conducted on institutionalized orphan children in Kashmir where the findings of the study showed the occurrence of high levels of anxiety disorders among the children. Orphanhood itself is the host of vulnerabilities of mental health and being under institutionalization led to increased risk of mental disorders and other psychosocial issues. As highlighted by Bhat et al., (2015), the long-term negative consequences of institutional placement on orphan children leave them in severe psychopathological issues and vulnerability.
The "UK Charity Winston's Wish" has conducted an evaluation study of residential group interventions on young people and children, and their carers/parents bereaved in traumatic circumstances. A number of the validated psychometric tests taken in the pre/post-intervention had indicated the positive results for the research participants (Trickey & Nugus, 2011). The research posits that children without parents faced a very risky life situation with no support of family and community. Due to lack of foods and facing healthcare problems, they were detached from the social network of families and this resulted in the creation of peculiar circumstances to the whole society (Hani, 2011). Although many studies on the effects of institutionalization and parental loss have been conducted on children in developed countries, the findings of these studies cannot be generalized to children in other countries with different cultural and economic backgrounds (Nsabimana et al., 2019).

Psychosocial Issues of Orphan Children
Without parents young children are at high risk of harm and experienced with different psychological, social, cognitive and attachment problems and, are probably evident in institutional care. According to UNICEF (2015) up to 85% of children in orphanages have at least one living parent in Nepal. A very high proportion of children living in institutions with the living biological parents in India, even without availability of accurate data. In Indonesia, 2007 survey revealed the children ratios living in institutions were around 90% with one living parent and 56% had both living parents. Studies by Save the Children in Sri Lanka indicated that approximately 80% of the children living in institutions have one or both living parents. These findings corroborated by data on household surveys indicate that living without parental care is the comparatively common phenomenon, while double orphan-hood is usually rare for 15 years below children. However, there are some exceptions. Like 66% children in Afghanistan are double orphans living in homes without parental care. But in 2009 report highlights that 70% of the children's living in alternative care have one parent alive in the same country (Flagothier, 2016).
The psychosocial paradigm by Erickson views that human development passes through eight defined stages of growth and development. Like the other development theories, the psychosocial theory postulate that social dysfunctions in adulthood are because of unresolved childhood conflict. Apparently, the main discourse running in all the paradigms outlined to implicates the unresolved childhood conflicts (Kng'ethe & Makuyana, 2014).
Psychosocial development life cycle remains valuable for the psychodynamic social practitioners. This theory brings out of narrow explanations of children bounds with nuclear family, and in developing social world interact with not only parents but peers and teachers too, the community members and caregivers into larger context of social and cultural prospect (Farinelli & Guerrero, 2011). A child's development can never acknowledge by study but examine the environments of social world in which child was developed. Child learn with others and share through interactions with external culture. Through educational goal is to generate the social learning development using social and culture relations (Penuel & Wertsch, 1995).
Theoretically, an infant with a warm response of care-giving develops an internal working model of expectations for nurturing reactions from that caregiver. The infant comes to trust this model of expectations and uses it, as a secure base from which to explore the physical and social world. Such experiences tend to promote the development of a sense of worth and self-esteem and appropriate long-term social and emotional development of health. Without the early experience of such an adult, long term development may be compromised (Huynh, 2014).
Institutional or residential care has provide some of the basic life supports but not able to provide other social/cultural and educational requirements (Bambo, Bth, Cnm, Ret, & Mph, 2013). The panorama of child welfare reformation in the system is valuable even if better social policy is transformed will be fundamentally dependent upon the support of scholars, parents, practitioners and ex-foster caregiver of children (Pelton, 2015). The inadequate and infrequent care giving to child contributes to weak physical growth. It stipulates the social and emotional interactions in a child to the stature psychosocial problem. When this interaction improved in an institution the physical development of child improve without changes in nutritional supplements (McCall, 2015).
A disparity in emotional disturbance is predominance in several demographic characteristics and that is the most common conditions of childhood problems. The untreated emotional and behavioural difficulties pose the permanent consequences frequently diagnosed in children (Henning-Smith & Alang, 2015). Children's development in institutions assesses the quality of care by caregiver and it depends on the interaction with each other. The level of physical and mental development of children proved the influence of care (McCall, 2015). It can be identified the significant difference of institutionalized and non-institutionalized orphan children in respect of their psychological conditions (Majeed, Khan, & Khan, 2014). Child bereavement endures a variety of factors that influence positively and negatively of their education. Like bereaved Harare schools children not received an adequate counselling about their bereavement due to the lack of school policies and planning (Shumba & Moyo, 2014).
Parental death affects the psychosocial functioning of children and adolescent's life. Loss of both parents has a momentous experience of psychosocial problems compared to those whose both parents alive. Parental death conceived the psychological trauma in childhood emotional and social development. Clinical research professed the attention towards the childhood parental death into long and short-term outcome of traumas. Evidence suggested that children bereavement enacted to vulnerable population at high risk for social deterioration (Raza, Adil, & Ghayas, 2008).
In Uganda children treated as like the adults, but adults often supposed that children could not contribute in social problems. Children are the part of society and their participation is the important challenge with cultural issues. Cultural advancement educate the children about their basic rights (Cheney, 2011). Media exposed children welfare problems complex and the professional involvement collaboration with media is completely overlaps in the society. The jobs of social workers have an immense role in educating of the students through media awareness programs. Through the media and public education works the life of deprived children and families issues must be addressed the problems (LaLiberte, Larson, & Johnston, 2011).
Several health symptoms in children like abdominal pain, headache, tense feeling, tiredness, and dizziness and sleeping problems presented into different conditions. Such health symptoms rates into time of bullying behaviour and dichotomized into other health problems (Gini, 2008). Children who grow up on an insufficient diet and lack of social relationships are more in stress and vulnerable to attend the school. Thus, such children in crises have increased probability of vulnerability to their future. But through the holistic approaches and address of their mental health and physical needs decreased the vulnerability from their early life (Jones, 2008).
Child welfare system required and deserves the special attention of researcher. In U.S every year, thousands of children placed in foster care. Through continued efforts and care by social workers, its generate the remarkable changes in lives of the children (Washington, 2008). A comparative study demonstrated the common behavioural problems in orphan and non-orphan children. In general, orphans reveal the emotional needs, poorness, insecurity, and abuse. Therefore, national policy is recommended for orphan children to cope with mental health challenges and setting up the strategy for counsellors in schools (Musisi, Kinyanda, Nakasujja, & Nakigudde, 2007). Literature showed that the study of socio-emotional development in children conduces to prevail the methodological issues and alignment across the research in constructs. There is close association between care quality of cognitive development or language with children socio-emotional development (Zaslow et al., 2006).
The role of social worker in child residential care as a profession reappraised the contest of their professional identity in the field of social work. In Scotland, the child residential care highlights the apparent efforts to conceptualize the knowledge base of social work and its identity paradigms. As suggested by Silove the possibility of controversies about the impact of psychical trauma of affected communities in disaster. Early traumatic stress reaction to be a normative success response encourages a strategy in identifying individuals who need quick professional intrusion, particularly within contexts of the sources and skills are limited. The starting position for psychosocial restoration is to make sure that the basic emergency reduction plan is oriented towards an approach that empowers to reproduce a cohesive and secure community. Within the particular broader humanitarian plan, there is really a vital area for mental wellbeing services that concentrate on the community of individuals whose mental disturbances on a survival risk (Silove, Steel, & Psychol, 2006).
A recent study revealed the considerable number of children's and adolescents in institutions across Europe that these young children without parents may be at highest prevalence of risk in institutional care. It's further reviewed the evident of institutional impact care on cognitive development, attachment, social behaviour and brain growth. The epidemiological study showed that children in institutional care are at substantial risk of harm in terms of developmental delays, cognitive domains, and attachment disorders. In residential care, the lack of direct relationship of primary caregiver is the significant cause of harm to the children. Research proved that infants in institutional care suffered to development. This neglect caused the penury and deprivation in children and they should have an opportunity to developed early in foster or family care environment (Johnson et al., 2006).

DISCUSSION
Research on the life of institutionalised bereaved children is seemingly limited. Childhood bereavement has a short and long-term repercussion on the wellbeing of children's, including their educational achievements and psychological health. However, there are very little clarity about the variety of support that these bereaved children need as well as the sort of support that were already provided for them (Akerman & Statham, 2014). If we ask these children about their well-being, we will certainly find that they are bound to have sensitive emotions, feelings, experience of close relationships and familial circumstances. They feel embarrassed, upset and intrusive due to these questions because this sort of questioning will lead them to their past experiences which may be related to abuse, neglect, bereavement and exploitation (Arieh, Ferran, Frønes, & Korbin, 2014).
The experience of going through difficult and disastrous events had left the orphan children in miserable conditions, which will possibly further exposed them to psychological traumas and deteriorate their living conditions. Noteworthy, Bowlby's attachment theory established that life span is comprised of a series of developmental stages, each with a major scope of developmental task. The article will serve as an avenue to understand the different challenges faced by the institutionalised bereaved orphan children, which in a sense provides justifications for the need to embark on a future research on psychosocial problems associated to the traumas experiences of this group of children.
Children is said to be in need of care and protection if he or she is exposed to moral danger or is out of control (Fuziah, 2016). The literature illustrates significant outlooks to recognize the association and perception of constructs, behaviours and dilemma related to attachment during bereavement. For instance, there is a need to conduct further research on residential and foster care institutions children in developing countries. We should not deny the existence of complicated grief among children. In fact, we really need to be aware of the potential consequences of grieving among children because "A child, when given adequate social and affective support, will in most cases overcome this life ordeal by giving it meaning" (Revet et al., 2020: 7). Further research is required including how best to support younger bereaved children. There is also a need for more empirically rigorous effect studies in this area (Bergman et al., 2017).

CONCLUSION
It is concluded that parental death in childhood is a traumatic experience that embedded the children to be at risk of various negative outcomes (Haine et al., 2008). This article provides a research gap pertaining to attachment theory from various perspectives. It reveals the psychosocial consequences of bereaved children living inside institutions. Furthermore, the use of qualitative case study research design would be an approach to explore and understand the imperative intervention strategies for maltreated and bereaved children living in residential and foster care institutions. This case study research could also examine the process of bereaved child development in the vulnerable communities. This focus becomes even more important given the presence of deterioration of life conditions and lack of care services, which could provoked the long-term consequences on the psychological development of these children.
This conceptual paper makes noteworthy contributions with regards to information on children and their psychosocial problems in institutions and residential cares. Despite its exploratory nature, this article offers some insight and preliminary interpretations of the range of emotional and behavioural problems experienced by bereaved children, which is likely to remain with them until adulthood. Such information is deemed important since it can be used to develop targeted interventions aimed at the children's psychological and social problems of the children. Moreover, more research is needed to provide a sound evidence-based programmes or interventions for bereaved children to sustain their future well-being. Hence, the primary goal of this article is to bridge the research-practice gap, which can be accomplished via in-depth examination of bereaved children in institutions.