A leading expert in child death investigations talks about his unlikely career.
A parent’s response to grief comes in many forms. And, after decades as a medical examiner, Dr. Thomas Andrew, among the country’s leading experts on child death, knows all about that.
Andrew is New Hampshire’s former chief medical examiner and spent decades conducting autopsies and describing to loved ones, often parents, about why somebody died.
Some are angry. Unlike in television crime shows, autopsies often don’t uncover an exact cause of death. In the case of one 15-month-old, however, Andrew did. An immune disorder that led to a widespread infection killed the child. But the parents, recent Russian immigrants who didn’t understand IVs and technology, didn’t believe it.
“They were convinced the child was killed by some sort of fluid mismanagement in the hospital,” Andrew said. “What I was trying to get across to them, which was hugely important, is that it’s a genetic disease. They needed genetic counseling. They need to strongly consider family planning going forward, but they were having none of it.”
In other cases, from the depths of their grief, they find unbelievable kindness. Andrew still gets emotional talking about the case of a seven-year-old boy who died during a pick-up basketball game. Andrew’s autopsy revealed that the boy had an undiagnosed congenital heart condition.
“When I called his father, and I explained what the findings were, he said, ‘Doc, I don’t know how you do this day after day,’ and he said, ‘How are you doing?’” Andrew remembers. “I just fell off my chair. Even as I tell the story now, I can’t believe he found the strength to ask that question. I just wanted to say, ‘Are you kidding buddy? Don’t think about me.’ That was an amazing, amazing experience.”
In his decades talking to mourning parents, “if you can imagine everything in between those two extremes,” he said, “I’ve seen it.”
An unlikely move
Andrew didn’t set out to spend his career analyzing why somebody died. It began with the goal of helping young people live. Fresh out of medical school, Andrew worked as a pediatrician — and loved parts of it, especially interacting with the kids.
“They bring so much to the table,” he said. “They are such intellectual sponges and are really curious about everything.”
But he didn’t enjoy the frenzied daily pace of ear checks and camp physicals. “I’m a plodder by nature,” he said. “I like to look at things from many different angles, and that didn’t fit with that model.”
At the same time, the cases that really engaged his intellect as a pediatrician were those that included aspects of forensic medicine, such as Sudden Infant Death Syndrome, consumer product safety issues and incidents of neglect.
Forensic medicine wasn’t a new topic for him. In medical school, a series of lectures in a basic pathology class captivated him and, as a senior, he completed a pathology rotation. Eventually, he made the switch to forensics.
Trying to answer, ‘Why?’
The job shifted from dealing daily with the living to studying the dead and explaining to their loved ones why they died. Andrew’s career took him from Ohio to New York City and, in 1997, to New Hampshire. Before retiring in 2017, he had conducted more than 5,200 autopsies to explain a sudden, unexpected or violent death.
And, with his training and work as a pediatrician, he carved out what he calls “a bit of a niche” in child deaths, focusing some of his writings on the topic. Today, Andrew’s White Mountain Forensic Consulting Services specializes in reviewing medical records and autopsies and testifying about deaths in criminal and civil cases.
Throughout his career, there was a common frustration: He couldn’t uncover why a child had died, yet he knew a family was desperate for answers.
In New Hampshire, parents often had two questions: Why did my baby die? And will this happen to my next one? They were queries that Andrew, many times, couldn’t fully answer.
But, despite their anguish and a lack of clear-cut answers, he said, it’s critical for medical examiners to be intellectually honest with families.
“To feel like you haven’t helped that family is a really empty and desolate feeling, but there is nothing crueler than a kind lie,” he said. “You’ve got to be totally honest with people when you don’t know those answers.”
And when they deliver their discoveries to families, medical examiners must be prepared to tailor their message to their audience. Empathy, he said, is critical in every conversation. If they can’t be sensitive to a specific family’s needs, they need to find a social worker or grief counselor who can. “They do more harm than good by being a bull in a china shop,” he said.
For families who seek answers, Andrew said their path doesn’t have to end with an inconclusive autopsy. He encourages parents to send their child’s case to researchers and groups, such as the Sudden Infant Death Syndrome Project, who are investigating particular health issues and causes of death.
“That’s what’s going to get answers sooner than later,” he said.
Finding the ‘trifecta’
These days, when he’s not testifying in a court case or reviewing medical records, Andrew is working on a master’s degree in divinity. He hopes to eventually become the full-time chaplain for the Daniel Webster Council of the Boy Scouts in New Hampshire. Both his faith and his involvement in Boy Scouts have provided a necessary relief from the seriousness of his day job.
And, after years of uncovering what bad decisions may have killed a person — whether it was drug abuse, dangerous driving or other unhealthy lifestyle choices — he’ll get to be on the front end of public health, providing tools for young people to help them make better decisions.
“Guiding these young people to make moral and ethical decisions, not only for their own sake, but the sake of others, it’s the trifecta,” he said. “I’ll get to do all these things that I love.”
47% of surveyed kids under age 18 believe their life will be harder than it will be for other people. Photo by Chinh Le Duc on Unsplash.
Evermore’s next few stories will have a “Back to School” theme focusing on both younger children and college-aged students. We are giving focus to siblings who have suffered the death of a brother or sister. Returning to school without their siblings can be painful reminder. Being with caring adults and peers who share their experience is extremely important. Bereaved parents are often so devastated by the death of their child, they can’t be there for their surviving children in the way they want to and need to be.
For centuries, children have grieved the death of a relative or friend. But, even just a couple of decades ago, there wasn’t really a field called “child bereavement” or a central organization to support the groups and individuals across the country who do the hard work to help kids in mourning.
To fill in the gaps, the National Alliance for Grieving Children formed nearly 25 years ago to create a network of people who provide services for kids who need them. And, today, the alliance’s membership has grown to 1,100. They include representatives from bereavement centers and hospices, along with social workers, child life specialists, school employees and others.
Vicki Jay, the alliance’s chief executive officer, said the lag to launch a bigger effort to support grieving children boils down, in part, to people’s discomfort with the topic.
“There are two natural things in life — birth and death,” Jay said. “We do everything in the world we can to plan for, anticipate and celebrate birth. And we, as a society, are not so eager to talk about the second topic. As a society, we haven’t done a lot of good work through the years of recognizing the importance of supporting people through that process.”
Vicki Jay, Chief Executive Officer.
What’s more, grieving children make adults uncomfortable. “We want to think kids are resilient,” she said. “They’ll be OK, and they’ll bounce back.”
In reality, she said, adults just don’t know what to do about kids who have experienced a death. “It’s easier to think that kids will be OK than trying to figure out how to help them,” Jay said. “Putting kids and grief in the same sentence makes a lot of people uncomfortable.”
But that’s what Jay and others at the alliance do on a daily basis. And their work has helped to uncover statistics that show that bereaved kids need help. Along with local grief support centers and the New York Life Foundation, the alliance conducted a national poll of 531 grieving children and teenagers, ages 18 and under, who were mourning the death of a parent or sibling.
The results, according to the alliance’s website, uncovered some sad realities:
86% of respondents said that they wish they had more time with their loved one, with 69% saying that they wish they could talk to their loved one, just one more time.
75% say the pervading emotion they currently feel is sadness, with feeling angry, alone, overwhelmed and worried being top other emotions.
73% said that they think about their loved one every day.
47% believe their life will be harder than it will be for other people.
46% cannot believe it is true.
Children also report trouble sleeping and concentrating on school work and that they’ve acted in ways that might not be healthy, according to the survey.
“When there is a death, I, as an adult, have a need to do something,” Jay said. “I call somebody. I cry. I pray. I research. I reach out. I make a casserole. I do something. And kids have that same need. Their tools are just different. We need to give them something to do that allows them to take that inside expression that they have and express it outwardly. … Our goal with kids is to give them the tools to get that inside stuff out.”
To help grieving kids, the alliance provides educational opportunities for the professionals who work with them and also connects children with services around the country. And, each November, it holds a National Childhood Bereavement Awareness Month to raise awareness about the needs of bereaved children.
Megan Lopez, National Program Director.
Jay, along with Megan Lopez, the alliance’s national program director, shared some tips for adults who are caring for grieving kids to help them understand their emotions. Here’s what they suggest.
#1 Talk about hard things
Adults often want to protect a child from hurtful or difficult-to-understand situations. But, when they do that, Jay said, they miss out on opportunities to have important talks about life and death. “We have multiple opportunities to help kids understand life and death and grief, and we need to capitalize on those,” she said. When those conversations take place, she said, you’re empowering them with information and knowledge.
#2 Expect unexpected reactions
Sobbing, deep sadness, exhaustion, changes in appetite and trouble sleeping are considered common reactions to grief. But, for kids, sometimes they just want to play or go back to school. “It doesn’t mean they’re not grieving,” Lopez said. “It means they’re a kid.”
#3 Look for change
Kids react to grief in any number of ways. “It looks like change for them,” Lopez said. “Maybe they were a very outgoing child before and now they’ve become more introverted. Maybe they were struggling with school and now they are really overachieving.”
What you’re looking for, she said, are changes to their typical behavior at home and school.
#4 Help them open up
It can be as simple as coloring a picture or playing with play dough together, Jay said. At night, she suggests, ask them what the best and worst thing is about their life. Find out what they’re excited and worried about.
Expect questions to come up months or years after the death as kids navigate through different developmental stages. “Give them multiple opportunities and modalities to help them express what’s inside and ask questions,” Jay said.
#5 Give them a safe space
Parents, of course, will want to ensure that children know they can go to them with questions. But adults also are grieving a loss. Lopez recommends providing other sources, who might be more removed from the family’s pain, where children can talk about their feelings. It might be a support group or with trusted friends.
“It’s about meeting the child where they are,” Lopez said. “Not giving them more information than they are ready to process, but being willing to keep having conversations. It’s not one and done.”
Julie Kaplow, on the left, serves as the Director of the Trauma and Grief Center in Houston, Texas, will be launching the Handle with Care program for children who have witnessed a death.
In August we are focusing on “Back to School” at Evermore. We are giving focus to siblings who have suffered the death of a brother or sister. Returning to school without their siblings can be painful reminder. Being with caring adults and peers who share their experience is extremely important. Bereaved parents are often so devastated by the death of their child, they can’t be there for their surviving children in the way they want to and need to be.
The research makes it clear: For children, bereavement is one of the top reasons they are clinically referred. It’s among the “most distressing life events” for children and adults. What’s more, children who are mourning the death of a family member or friend have a higher risk for depression, substance abuse and other mental or behavioral health problems later in life.
Researcher Julie Kaplow, along with other experts, spell out these facts in a 2018 report that considers a tool used to assess bereavement in youth. The death of a parent, sibling or other relative or friend is a setback for any child, but some children develop unhealthy strategies to cope with the loss. There aren’t enough tools, especially for youth, that clinicians and counselors can use to evaluate whether a child could use extra support.
“We need assessment tools that tell us that this kid is not grieving in a way that’s healthy and we need to find some help,” said Kaplow, considered one of the nation’s top experts and thought leaders on grief and children.
In her many jobs, Kaplow’s work to develop those assessments is part of a multi-pronged approach that she and other researchers are tackling to support traumatized and bereaved children.
Kaplow is director of Texas Children’s Hospital’s Trauma and Grief Center, a Substance Abuse and Mental Health Services Administration-funded center that’s part of the National Child Traumatic Stress Network. The network, which includes 100 sites across the country, aims to raise the standard of care and bolster access to services for traumatized children and their families. The center at Texas Children’s is the only one to focus specifically on grief and bereavement.
Kaplow also serves as chief of psychology at the Houston hospital where she oversees 60 clinical psychologists. And, she is vice chairman for behavioral health at Baylor College of Medicine where she supervises behavioral health initiatives.
Healthy, unhealthy coping
Death is hardly a new topic, but grief and how we cope with it is a newer field of research, especially as it pertains to bereaved children.
“It’s controversial to talk about grief as a psychological problem given that bereavement is a natural part of life,” Kaplow said. “We know that everyone will have to experience a death at some point. We don’t want to pathologize normal grieving. I think there’s been such a push in that direction that it’s been at the expense of recognizing that there are some kids who really do get stuck and who really do need an additional level of support. I think that is what’s hindered the field.”
There are plenty of factors that can help to determine how a child will cope with a death over time, Kaplow said.
“What we know is if children are brought up in a healthy, happy environment, and if somebody dies, those kids, most of the time, will end up still continuing to lead happy, healthy lives,” she said.
“Kids who already bring with them other adverse experiences or a lack of parental support, even before the death, can have more trouble. So can children whose loved one died by homicide or suicide or who are living in poverty or in neighborhoods where violence is the norm,” Kaplow said.
“Maladaptive grieving can manifest in a number of different ways, and that depends on the developmental stage of the child,” she said.
A younger child may exhibit more clinginess, separation anxiety, a new onset of fears or developmental delays. A teenager might get involved in more risk-taking behaviors or even consider suicide. “And that can be either wanting to reunite with the person who died, if that’s part of their belief system, … or just not caring about life anymore,” Kaplow said.
Better treatments
To help those kids, Kaplow and her colleagues have developed evidence-based treatments that are designed to support traumatized or grieving children.
Trauma and Grief Component Therapy can be tailored to an individual child’s specific needs. A child mourning a loved one will benefit from the modules designed for grieving kids. Another child, who has been abused or witnessed violence, but hasn’t experienced a death, can benefit from the trauma modules.
The Trauma and Grief Center’s goal is to raise awareness about the adaptive side of grief, while also helping to identify bereaved youth who may need a higher level of support.
Multidimensional Grief Therapy is for kids who have experienced a death and are struggling. “It’s designed to address the different bereavement-related challenges kids may have,” she said.
Now, Kaplow and her colleagues are training others to provide these therapies to the kids who need them.
Targeting schools
There is much more work to do, of course, to help communities and clinicians assist kids who are mourning. And schools, said Kaplow, where children spend so much of their time, are an obvious place to start.
In the next six months, Kaplow plans to launch the Handle with Care program in Houston. Already in West Virginia and San Antonio, the program provides a way for police to alert school principals when a child has witnessed a death. From there, the child’s teacher can monitor them for post traumatic stress disorder and refer them to the school counselor, if needed.
Another major initiative is to ensure that school-based clinicians and teachers are trained to identify PTSD symptoms and children who are not coping well with their grief.
“Bereavement has been one of those sleeper traumas that not a lot of schools have paid close attention to,” Kaplow said. “What we’re finding is that bereavement is the №1 predictor of school failure above and beyond any other form of trauma and that includes sexual abuse, physical abuse and witnessing domestic violence.”
“Knowing bereavement is the most prevalent form of trauma, we definitely need to be helping teachers to ask questions and be more direct about inquiring about a recent loss,” she said. “We know that it’s uncomfortable for people. We don’t want to bring it up. But we also know it’s never harmful to inquire about how a child is coping after a death.”
Two grieving mothers seek efforts to bring transparency, safety to college abroad programs
Ros Thackurdeen remembers the hype as she sat through a college study abroad session with her youngest son Ravi at Swarthmore University.
“It was pretty exciting,” Thackurdeen said. “I wanted to go on it. You had students who talked about their experiences … You didn’t hear anything bad about it.”
But there was no happy ending for Ravi, who ended up on a study abroad trip to Costa Rica to study global health and tropical medicine. In April 2012, program leaders took Ravi’s group on a surprise trip to Playa Tortuga which, Thackurdeen has since learned, is considered one of the country’s most dangerous beaches. A local fisherman found Ravi’s body two days later.
“I thought it was study abroad’s first death,” Thackurdeen said. But, not long after, she searched study abroad student death on Google and was surprised by what she found — 85 pages of links and stories about the deaths of other college students like Ravi. She started printing out the stories, filling up binders with information and reaching out to officials with questions about safety measures.
“I wanted them to see the faces because I was seeing faces and that was hitting me really hard,” she said. “That is somebody’s child just like my child, and they too are going through the same pain that I’m going through.”
Through her research, Thackurdeen eventually met Elizabeth Brenner, whose youngest son Thomas died while studying abroad in India in September 2011. Together, the two founded Protect Students Abroad, a nonprofit that is working on efforts to prevent fatalities on study abroad programs and provide transparency so parents and students can make smart decisions.
“I can’t abandon this,” Brenner said. “I wouldn’t know how to abandon this. It’s really, really hard. But there is, at this point, because of everything that’s happened and because of the person that I am now, no other choice.”
No mandatory reporting
Study abroad programs are growing. The Institute of International Education’s 2018 Open Doors report found that the total number of U.S. students studying overseas grew by 2.3% in 2016–17 when compared to the year before. About 10% of the country’s undergraduate students study abroad.
But, said Brenner and Thackurdeen, parents and students often know little about the programs.
“If the third party program appears on the university’s website and if they appear in a study abroad forum, most parents and students assume that the home university has eyes on the program,” Brenner said. ”Nothing can be further from the truth. And on the backend of it, if it goes wrong, every single parent we have met with talk about how far the programs will scurry away [saying] ‘This isn’t our program. We have nothing to do with this.’ There isn’t a requirement. Parents find out on the backend, and the waivers are really, really tight.”
For both Brenner and Thackurdeen, that lack of support and transparency is part of the problem. For many parents who are grieving a child who died overseas, it can be almost impossible to find out the details of their death.
“There’s no mandatory reporting at all,” said Brenner. “So, potentially, you will get the narrative that they would like to have been true. … We know of families who really struggle to figure out what really happened to their child.”
Brenner and Thackurdeen are luckier. For Brenner, a student newspaper reporter took an interest in the case. Together, the two traveled to India and were able to find out what happened. Students who were on the trip with her son also provided some answers. Thackurdeen got answers from a couple who were taking a walk on the beach and witnessed what happened, along with some of the other students who were on the trip.
“You may spend the rest of your life not knowing what happened and not getting the truth from anyone,” Brenner said. “It adds a whole different layer to the experience.”
Pushing for passage
Together, Brenner and Thackurdeen want to prevent other families from suffering similar heartbreaks. The two are working to secure the passage of two federal bills that would provide families with more transparency when a student dies on a study abroad program and help other families make informed decisions about which program to send their child on.
“One of the first things that surprised me was finding out after Thomas died that it was his program’s 12th death,” Brenner said.
Both bills, which have bipartisan support and have been introduced in the U.S. House and U.S. Senate, tackle the issue from different angles and, Brenner and Thackurdeen said, are needed.
Named after Thackurdeen’s son, the Ravi Thackurdeen Safe Students Study Abroad Bill amends the Higher Education Act of 1965 to require colleges and universities to report safety incidents, including deaths, accidents and illnesses requiring hospitalization, sexual assaults and events that generate a police report.
The American Students Abroad Act requires that the U.S. Department of State share consular reports of U.S. citizen deaths abroad to the Centers for Disease Control and Prevention, so that the CDC can analyze the data to uncover patterns and find ways to prevent these deaths and injuries.
Despite their own family’s experiences, both Brenner and Thackurdeen still support opportunities to study abroad. Each have two other children who went overseas on study abroad trips.
“We hear back from programs and colleges that this will hamper us, cut into study abroad growth,” Thackurdeen said. “That’s just not going to happen. One of our student interns is going on her study abroad. She’s very much aware from working with us of some of the dangers, and she’s using that information to ask questions and educate herself about it.”
For parents and students who are contemplating a study abroad program, Brenner and Thackurdeen have some advice.
#1 Educate yourself
Check out Protect Students Abroad’s website to learn more about the safety issues for students traveling abroad. “It’s really learning, firsthand, from what we’ve gone through and taking that information and asking better questions and doing some of the research,” Thackurdeen said.
#2 Make sure your child’s prepared
Encourage your child to read local newspapers from the area where they are traveling and remind them about the importance of being aware of their surroundings at all times.
#3 Ask the hard questions
Seek out statistics about injuries or deaths. Ask about safety measures. Make sure you truly understand the relationship between your child’s home university, the study abroad program and the host country.
“They may not be in alignment or communicating with each other even though it looks like they are from the website or from the study abroad forum your child went to or the literature that has come home with your child,” Brenner said.
#4 Read the waiver
Said Thackurdeen: “Look very hard at the waiver before they sign it. If you are uncomfortable with the language of it, speak to a personal attorney. It’s not about money. It’s about having your day in court.”
“And getting the truth,” added Brenner. “How many of us are fighting to just get the facts about what happened to our child.”
Brenner and Thackurdeen encourage others to ask their U.S. Senator and U.S. Representative to support the two bills in Congress, S. 1572 and S. 1575 in the Senate, and H.R. 2875 and H.R. 2876 in the House.
