Grief and Developmental Stages
        Infants
        Ages 2 to 3 years
        Ages 3 to 6 years
        Ages 6 to 9 years
        Ages 9 years and older
        Issues for grieving children
Interventions for Grieving Children
        Explanation of death
        Correct language
        Planning rituals
        References and resources for grieving children

At one time children were considered miniature adults, and their behaviors were expected to be modeled as such.[1] Today there is a greater awareness of developmental differences between childhood and other developmental stages in the human life cycle. Differences between the grieving process of children and that of adults are recognized. It is now believed that the real issue for grieving children is not whether they grieve, but how they exhibit their grief and mourning.[1]

The primary difference between bereaved adults and bereaved children is that intense emotional and behavioral expressions are not continuous in children. A child’s grief may appear more intermittent and briefer than that of an adult but in fact usually lasts longer.[1-3] The work of mourning in childhood needs to be addressed repeatedly at different developmental and chronological milestones. Because bereavement is a process that continues over time, children will revisit the loss repeatedly, especially during significant life events (e.g., going to camp, graduation from school, marriage, and the birth of their own children). Children must complete the grieving process, eventually achieving resolution of grief.

Although loss is unique and highly individualized, several factors can influence a child’s grief. These factors include the child’s age, personality, stage of development, previous experiences with death, previous relationship with the deceased, the environment, the cause of death, patterns of interaction and communication within the family, stability of family life after the loss, how the child’s needs for sustained care are met, availability of opportunities to share and express feelings and memories, parental styles of coping with stress, and the availability of consistent relationships with other adults.[2-4]

Children do not react to loss in the same ways as adults and may not display their feelings as openly as adults do. In addition to verbal communication, grieving children may employ play, drama, art, school work, and stories.[5] Bereaved children may not withdraw into preoccupation with thoughts of the deceased person; they often immerse themselves in activities (e.g., they may be sad one minute and then playing outside with friends the next). Families often incorrectly interpret this behavior to mean the child does not really understand or has already gotten over the death. Neither assumption may be true; children's minds protect them from thoughts and feelings that are too powerful for them to handle. Grief reactions are intermittent because children cannot explore all their thoughts and feelings as rationally as adults can. Additionally, children often have difficulty articulating their feelings about grief. A grieving child’s behavior may speak louder than any words he or she could speak. Strong feelings of anger and fear of abandonment or death may be evident in the behaviors of grieving children. Children often play death games as a way of working out their feelings and anxieties in a relatively safe setting. These games are familiar to the children and provide safe opportunities to express their feelings.[1,2]

Death and the events surrounding it are understood differently depending on the age and developmental stage of the child.

Although infants do not recognize death, feelings of loss and separation are part of a developing death awareness. Children who have been separated from their mothers and deprived of nurturing can exhibit changes such as listlessness, quietness, unresponsiveness to a smile or a coo, physical changes (including weight loss), and a decrease in activity and lack of sleep.[6]

In this age range, children often confuse death with sleep and can experience anxiety. In the early phases of grief, bereaved children can exhibit loss of speech and generalized distress.[3,6]

In this age range, children view death as a kind of sleep: the person is alive, but in some limited way. They do not fully separate death from life and may believe that the deceased continues to live (for instance, in the ground where he or she was buried) and often ask questions about the activities of the deceased person (e.g., how is the deceased eating, going to the toilet, breathing, or playing?). Young children can acknowledge physical death but consider it a temporary or gradual event, reversible and not final (like leaving and returning, or a game of peek-a-boo). A child’s concept of death may involve magical thinking, i.e., the idea that his or her thoughts can cause actions. Children may feel that they must have done or thought something bad to become ill or that a loved one’s death occurred because of some personal thought or wish. In response to death, children younger than 5 years will often exhibit disturbances in eating, sleeping, and bladder or bowel control.[3,6]

It is not unusual for children in this age range to become very curious about death, asking very concrete questions about what happens to one’s body when it stops working. Death is personified as a separate person or spirit: a skeleton, ghost, angel of death, or bogeyman. Although death is perceived as final and frightening, it is not universal. Children in this age range begin to compromise, recognizing that death is final and real but mostly happens to older people (not to themselves). Grieving children can develop school phobias, learning problems, and antisocial or aggressive behaviors; can exhibit hypochondriacal concerns; or can withdraw from others. Conversely, children in this age range can become overly attentive and clinging. Boys may show an increase in aggressive and destructive behavior (e.g., acting out in school), expressing their feelings in this way rather than by openly displaying sadness. When a parent dies, children may feel abandoned by both their deceased parent and their surviving parent, since the surviving parent is frequently preoccupied with his or her own grief and is less able to emotionally support the child.[3,6]

By the time a child is 9 years old, death is understood as inevitable and is no longer viewed as a punishment. By the time the child is 12 years old, death is viewed as final and universal.[3,6]

In American society, many grieving adults withdraw into themselves and limit communication. In contrast, children often talk to those around them (even strangers) as a way of watching for reactions and seeking clues to help guide their own responses. It is not uncommon for children to repeatedly ask baffling questions. For example, a child may ask, “I know Grandpa died, but when will he come home?” This is thought to be a way of testing reality for the child and confirming the story of the death.

There are three prominent themes in the grief expressions of bereaved children:

1. Did I cause the death to happen?
2. Is it going to happen to me?
3. Who is going to take care of me?[2,7]

Did I cause the death to happen?

Children often engage in magical thinking, believing they have magical powers. If a mother says in exasperation, “You’ll be the death of me,” and later dies, her child may wonder whether he or she actually caused the death. Likewise, when two siblings argue, it is not unusual for one to say (or think), “I wish you were dead.” If that sibling were to die, the surviving sibling might think that his or her thoughts or statements actually caused the death.

Is it going to happen to me?

The death of a sibling or other child may be especially difficult because it strikes so close to the child’s own peer group. If the child also perceives that the death could have been prevented (by either a parent or doctor), the child may think that he or she could also die.

Who is going to take care of me?

Because children depend on parents and other adults for their safety and welfare, a child who is grieving the death of an important person in his or her life might begin to wonder who will provide the care that he or she needs now that the person is gone.

There are interventions that may help to facilitate and support the grieving process in children.

Silence about death (which indicates that the subject is taboo) does not help children deal with loss. When death is discussed with a child, explanations should be kept as simple and direct as possible. Each child needs to be told the truth with as much detail as can be comprehended at his or her age and stage of development. Questions should be addressed honestly and directly. Children need to be reassured about their own security (they frequently worry that they will also die or that their surviving parent will go away). A child’s questions should be answered, and the child's processing of the information should be confirmed.

Although it is a difficult conversation to initiate with children, any discussion about death must include proper words (e.g., cancer, died, or death). Euphemisms (e.g., “he passed away,” “he is sleeping,” or “we lost him”) should never be used because they can confuse children and lead to misinterpretations.[3,8]

After a death occurs, children can and should be included in the planning of and participation in mourning rituals. As with bereaved adults, these rituals help children memorialize loved ones. Although children should never be forced to attend or participate in mourning rituals, their participation should be encouraged. Children can be encouraged to participate in the aspects of funeral or memorial services with which they feel comfortable. If the child wants to attend the funeral (or wake or memorial service), it is important that a full explanation of what to expect is given in advance. This preparation should include the layout of the room, who might be present (e.g., friends and family members), what the child will see (e.g., a casket and people crying), and what will happen. Surviving parents may be too involved in their own grief to give their children the attention they need. Therefore, it is often helpful to identify a familiar adult friend or family member who will be assigned to care for a grieving child during a funeral.[8]

There is a wealth and variety of helpful resources (books and videos) that can be shared with grieving children.

1. Worden JW: Children and Grief: When a Parent Dies. New York, NY: The Guilford Press, 1996.



2. Doka KJ, ed.: Children Mourning, Mourning Children. Washington, DC: Hospice Foundation of America, 1995.



3. Wass H, Corr CA: Childhood and Death. Washington, DC: Hemisphere Publishing Corporation, 1984.



4. Corr CA, McNeil JN: Adolescence and Death. New York, NY: Springer Publishing Company, 1986.



5. Corr CA, Nabe CM, Corr DM: Death and Dying, Life and Living. 2nd ed., Pacific Grove: Brooks/Cole Publishing Company, 1997.



6. Grollman EA: Talking About Death: A Dialogue Between Parent and Child. 3rd ed., Boston, Mass: Beacon Press, 1990.



7. Schaefer D, Lyons C: How Do We Tell the Children?: Helping Children Understand and Cope When Someone Dies. New York, NY: Newmarket Press, 1988.



8. Wolfelt A: Helping Children Cope with Grief. Muncie: Accelerated Development, 1983.



9. Walker A: To Hell with Dying. San Diego, Ca : Harcourt Brace Jovanovich, 1988.



10. Williams M: Velveteen Rabbit. Garden City: Doubleday, 1922.



11. Viorst J: The Tenth Good Thing About Barney. New York, NY: Atheneum, 1971.



12. Tiffault BW: A Quilt for Elizabeth. Omaha, Neb: Centering Corporation, 1992.



13. Levine JR: Forever in My Heart: a Story to Help Children Participate in Life as a Parent Dies. Burnsville, NC: Mountain Rainbow Publications, 1992.



14. Knoderer K: Memory Book: a Special Way to Remember Someone You Love. Warminster,Pa: Mar-Co Products, 1995.



15. de Paola T: Nana Upstairs and Nana Downstairs. New York, NY: GP Putnam’s Sons, 1973.

References

1. O'Toole D, Cory J: Helping Children Grieve and Grow: a Guide for Those Who Care. Burnsville, NC: Compassion Books, 1998. 
   
   
2. Corr CA, Nabe CM, Corr DM: Death and Dying, Life and Living. 2nd ed. Pacific Grove, Calif: Brooks/Cole Publishing Company, 1997. 
   
   
3. Fitzgerald H: The Grieving Child: A Parent's Guide. New York: Fireside, 1992. 
   
   
4. DeSpelder LA, Strickland AL: The Last Dance: Encountering Death and Dying. 4th ed. Palo Alto, Calif: Mayfield Publishing Company, 1996. 
   
   
5. Goldman A: ABC of palliative care. Special problems of children. BMJ 316 (7124): 49-52, 1998.  [PUBMED Abstract]
   
   
6. Burnell GM, Burnell AL: Clinical Management of Bereavement: A Handbook for Healthcare Professionals. New York: Human Sciences Press, Inc., 1989. 
   
   
7. Worden JW: Children and Grief: When a Parent Dies. New York: The Guilford Press, 1996. 
   
   
8. Kastenbaum R: Death, Society, and Human Experience. Boston: Allyn and Bacon, 1995. 
   
   

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