When a family suffers the death of a child, the reverberations can extend beyond the immediate period of bereavement. When a child is born into a family that has suffered such a loss, there is concern that the new child might be compromised in his or her development. Such a baby is often described as a "replacement child," a substitute or replacement for the child who died. This baby is thought to be at risk for later psychological difficulties because of an inability to form an identity separate from the dead child. It is thought that parents who are unable to fully and completely mourn the death of their child may compromise a subsequent child's mental health by imbuing that child with the qualities and characteristics of the dead sibling and by continuing to mourn the earlier death.
The death of a child is among the most profound losses that an individual can suffer, and the resulting grief can be especially intense and prolonged. This is in part due to the uniqueness of the parent-child relationship. From the moment of conception, the parents fantasize about the child-to-be, investing in him or her their hopes and dreams for the future. Parents see themselves in their children, and when the child dies, it is as if a part of the parent dies, too. Parents also feel acutely the loss of the parenting role when their children die. The social role of parent, which can begin at conception, is an important organizer of time, activity, and identity. The loss of the parental role often challenges the parent's sense of meaning or purpose in life. The death of a child also changes the nature and composition of the family constellation and alters the family story.
Parents cope with the death of a child in multiple ways. Often, particularly when the death occurs during or shortly after birth, parents express the desire to have another child. They feel a strong need to fulfill the expectations created by the previous pregnancy and assume the parenting role. When the child that dies is older, parents may feel the need to fulfill the expectations, hopes, and dreams engendered by the dead child.
The Replacement Child As a Clinical Phenomenon
There has been much concern in mental health literature about families inadvertently creating replacement children. This phenomenon was first described in a 1964 paper by Albert and Barbara Cain, who reported on six families receiving psychiatric treatment following the death of a child or adolescent and the birth of a subsequent child who later developed psychiatric problems. This clinically important paper led to the prominence of the term replacement child in the mental health field. The parents in the Cain and Cain study were characterized by intense idealization and investment in the dead child, maternal personality dysfunction that predated the child's birth, and a history of losses in the mother's own childhood. The parents were restrictive and overprotective, and the children were fearful, anxious, morbidly preoccupied with death, and lacking in self-esteem. The authors of this study warned that parents should not have another child until they have had the opportunity to completely mourn the death of their child.
Although Cain and Cain note that the replacement of a child who dies at birth or in infancy is less likely to be complicated by confused identifications and comparisons with siblings, other clinicians suggest there may be some risk when a child dies at or near birth as well. In this case, the parents' experience with their baby is very limited. They have few memories to mourn and instead must mourn the wishes and expectations that they held for the child. The baby remains an abstraction even after the death.
The replacement-child concept has influenced contemporary obstetric and neonatal caregiving practice. When a child dies during the perinatal period (at or near birth), parents are encouraged to have contact with the dead baby, including holding and naming him or her, taking pictures, and making memories. It is suggested that parents who have these experiences are better able to grieve the loss, can separate the real baby from the fantasy image they hold, and thus may be better able to parent a subsequent child. Medical personnel have often counseled parents who have experienced perinatal loss to wait before attempting subsequent pregnancies in order to grieve fully for the dead child.
Research into Parents' Opinions
There is a considerable body of psychiatric case studies on the pathology of the replacement child. Studies that solicit parents' opinions suggest that giving birth after the death of a child may be helpful to the parents and help families grow through loss. One researcher found that recently bereaved parents experienced their loss as a void or hole in the family. For some parents, the decision to have another child provides a reason to begin living again. Although parents indicate that they could not replace the dead child, many want another child of the same sex as soon as possible and often give the subsequent child a name that resembles that of the dead child.
It is important to directly assess the psychological functioning of children born subsequent to parental bereavement. Parental attitudes toward the decision to have other children, parental beliefs about practices, and parents' interpretation of the family structure directly and indirectly affect child mental health. Parental interpretations of the family constellation and stories about family life determine family practices and, through these practices, child development. Family stories give meaning to the past and direction to the future, shaping subsequent development.
What Family Practices Say about Subsequent Children
By listening to and analyzing the stories of parents who have lost children at or near birth and who have gone on to have subsequent children, it is apparent that many parents do not replace the dead child with a child born later. Some parents continue to represent their family as including their deceased child and maintain an imagined relationship with the dead child that is separate and apart from their relationship with their living children. Other parents continue for years to feel the death of their child as a hole or void in the family constellation. Other parents may, in fact, fill in the gap in the family with a newborn "replacement child." Many parents continue to remember and pay homage to their dead child long past the initial mourning period. None of these arrangements or representations of family are necessarily pathological.
Theoretical Constructions of Grief and the Replacement Child: Stage Models
Concerns about the risk of having a replacement child are derived from a stage model of grieving. This way of understanding grief suggests that there is a typical pathway through grief and a "good" and "bad" way to grieve. The "good" way consists of moving from a period of shock or denial, through an intensely painful period during which the deceased is acutely missed and the bereaved may feel guilty and angry as well as sad, followed by a period of grief resolution characterized by changed or diminished attachment to the deceased, loosened emotional bonds, reinvestment in the social world, and return to preloss levels of functioning. A "bad" way would include denial of the loss or premature focus on moving forward. Cain and Cain note that the replacement children in their study represent a "pseudoresolution" of mourning because there is a denial of loss and a retention of intense emotional ties to the dead child.
Some psychologists suggest that the grieving is a means of reconstructing meaning in the face of a world that has irrevocably changed. Making meaning is, of course, highly personal, and the meanings a grieving individual creates are unique. Hence there is no universal path through grief, and no practice (i.e., replacing a child) can be prescribed or be considered detrimental on its face. Rather, the place the child holds in the family story and the meanings the parents ascribe to the dead child and the surviving and subsequent children require individual assessment. Further, contemporary models of grief note the commonality and normalcy of maintaining continuing bonds to the deceased. Thus, a continued relationship with the dead child, considered pathological in the Cain and Cain study, is increasingly noted as common practice and one that does not necessarily interfere with the growth and development of surviving children.
While the replacement-child construct may have clinical utility, especially in cases where parents may have preexisting dysfunction and/or a significant history of losses, it seems clear that clinical axioms like "replacement child" do not do justice to the complexity of parental interpretations of the child and the family constellation. When parents are asked to describe how they coped with the loss of a child, and when families who have experienced the birth of a child subsequent to a loss describe their experiences, it becomes clear that there are many paths through this grief that do not result in the anticipated pathology. As caregivers for families who have experienced the death of a child, one must seek to understand the meaning of the dead child and subsequent children, and what those children represent to their families. Without listening closely to the stories that parents tell, mental health practitioners are in danger of assuming psychological risk when there may be none.
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LESLIE A. GROUT BRONNA D. ROMANOFF