Background    An understanding of age-appropriate grief reactions and conceptions of death are important when assessing a child’s response to terminal illness and a loved one’s death.  This Fast Fact reviews key developmental concepts and describes strategies for addressing children’s grief.

Children grieve differently than adults. They often grieve in spurts and can re-grieve at new developmental stages as their understanding of death and perceptions of the world change. Childhood grief may be expressed as behavioral changes and/or emotional expression.  The two most important predictive factors of a child’s successful outcome after suffering a loss are the availability of one significant adult and the provision of a safe physical and emotional environment.

0-2 years (Infant) Children at this age have no cognitive understanding of death.  However, grief reactions are possible and separation anxiety is a concern. Behavioral and developmental regression can occur as children have difficulty identifying and dealing with their loss; they may react in concert with the distress experienced by their caregivers. There is a need to maintain routines and to avoid separation from significant others.

2-6 years (Preschool) Preschool age children see death as temporary and reversible. They interpret their world in a concrete and literal manner and may ask questions reflecting this perspective. They may believe that death can be caused by thoughts and provide magical explanations, often blaming themselves for the death.  Providing simple and straightforward explanations, avoiding euphemisms, correcting misperceptions, and reminding them that the loved one will not return are important strategies.

6-8 years (School Age) Children understand that death is final and irreversible but do not believe that it is universal or could happen to them. Death is often personalized and/or personified. Expressions of anger towards the deceased or towards those perceived to have been unable to save the deceased can occur. Anxiety, depressive symptoms, and somatic complaints may be present. The child often has fears about death and concerns about their other loved ones’ safety. In addition to giving clear, realistic information, offer to include the child in funeral ceremonies. Notifying the school will help teachers understand the child’s reaction and provide additional adult support.

8-12 years (Pre-adolescent) Children at this age have an adult understanding of death – that it is final, irreversible, and universal. They can understand the biological aspects of death as well as cause-and-effect relationships. They tend to intellectualize death as many have not yet learned to identify and deal with feelings. They may develop a morbid curiosity and are often interested in the physical details of the dying process as well as the religious and cultural traditions surrounding death. The ability to identify causal relationships can lead to feelings of guilt; such feelings should be explored and addressed. To facilitate identification with emotions, it may prove useful to talk about your own emotions surrounding death and to offer opportunities for the child to discuss death. The child should also be allowed to participate, as much as they feel comfortable, in seeing the dying patient and participating in activities surrounding the death.

12-18 years (Adolescent) Adolescents also have an adult understanding of death. They are developing the ability to think abstractly and are often curious of the existential implications of death. They often reject adult rituals and support and feel that no one understands them. They may engage in high-risk activities to challenge their own mortality more fully. They often have strong emotional reactions and may have difficulty identifying and expressing feelings. It is important that adults support independence and access to peers, but to also provide emotional support when needed.

Summary The generalizations and strategies provided above only serve as a framework when dealing with the death of a loved one. When in doubt, seek help from pediatricians, child-life specialists, mental health professionals, and others specializing in bereavement.

References

1. Gudas LS, Koocher GP.  Grief and Bereavement.  In: Behrman RE, Kliegman RM, Jenson HB, eds.  Nelson Textbook of Pediatrics. 17^th ed. Philadelphia, PA: Saunders; 2004.
2. Himelstein BP, Hilden JM, Boldt AM, Weissman D.  Pediatric palliative care.  N Engl J Med.  2004; 350:1752-1762.
3. Trozzi M, Dixon S.  Stressful Events: Separation, Loss, Violence, and Death.  In: Dixon SD, Stein MT, eds.  Encounters with Children: Pediatric Behavior & Development. 3^rd ed.  St Louis, MO: Mosby; 2000.
4. Fine P, ed.  Processes to Optimize Care During the Last Phase of Life.  Scottsdale, AZ:  Vista Care Hospice, Inc.; 1998.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in June 2005. Version re-copy-edited in April 2009; then again in October 2015.