It is estimated that over 2 million children in the United States alone, or slightly more than 3%, experience the death of a parent before the age of 18. 1 Almost three-quarters of these are anticipated. The percentage is much higher when the statistics include experiences children usually have, such as death of grandparents, relatives, siblings, classmates, and pets. With tragedy occurring throughout the world, children are also exposed to loss of life many times over before they become adults. Thus it is not possible to shield children or protect them from this reality, nor should adults try. We have come to realize that in fact children do grieve and they can be helped with the grieving process.
Types of loss
The actual physical loss of a person is the primary loss experienced by the child. The meaning of the individual for the child will be felt in countless ways throughout the child's life. However, death is more than loss of the individual's physical presence. Secondary losses or changes impact the child in significant ways. These include:
- Loss and change of self: Individuals are defined in many different ways. One's identity, self-confidence, sense and understanding of physical health, one's personality, and one's role in the family can be changed by a death.
- Loss and change of security: One's sense of emotional and physical safety is often shaken. In addition, a change in financial security and lifestyle may accompany and add to aspects of one's life affected by the loss.
- Loss and change of meaning: A restructuring and re-evaluation of goals and dreams is not uncommon. In addition, children and teens may re-examine and question their faith and even the desire to live and the ability to regain a sense of joy.
Factors affecting short and long term adaptation
A variety of factors influence a child's adjustment to death. These include:
- Type of death. Any death is painful and a life-changing experience. However, when the death follows a prolonged illness, the family has the opportunity to prepare, plan for closure, be involved in the dying process, and perhaps put preventive mental health measures in place. The shock of a sudden death can make it more difficult to comprehend and acknowledge, resulting in different emotions. Certain causes, such as suicide, homicide, AIDS or drug-overdose still carry shame and embarrassment, further complicating grief and mourning.
- Physical and emotional functioning of the surviving adults/parents. Children are reactive to their parent's response. If grief and sadness overwhelm a parent, the child may be scared by such intense emotion. Likewise, a parent who is in denial may confuse or limit a child's own expression of sadness. In addition, a child may be affected by a parent's physical or emotional availability.
- Demographic characteristics of the child and family such as age, socioeconomic status. Children's ability to understand the full meaning of a death is limited by their age and cognitive understanding of death. Families may also be more or less limited in their ability to access help for immediate and long-term needs.
- Child's personality and temperament. Children have their own individual styles of functioning and coping and at a time of crisis certain characteristics can be exaggerated and certain resources will be called upon. A cautious or anxious child may be more fearful for a time and a child who is practical may set about quickly re-establishing a routine.
- Pre-existing risk factors such as prior mental illness, learning or social problems. Children with other problems may be more challenged in their ability to cope with a loss. They may have more difficulty understanding or managing the changes in their life or they may have poor social skills or strained social relationships with peers, making it more difficult for them to benefit from supportive friendships.
- Family structure, functioning and relationship. All families have a particular style for functioning and relating. Those that have an open system of communication and a strong structure will provide comfort and assurance for children. Strained relationships, fighting, existing resentments or conflicts may interfere with the family's ability to band together.
- Quality of the prior relationship. The type of relationship shared between two people prior to a death impacts how the loss is felt and the emotional recovery. Siblings, who fought in a normal fashion, may feel the loss of a playmate when a sibling dies but may also feel regret and blame. Likewise, a rebellious teen may feel guilty for harsh words said to a parent in a moment of anger.
- Concurrent life stressors such as financial problems, difficult living situations, divorce or illness. Other existing stresses can make adjustment to a death more complex and leave the child and family feeling overwhelmed or empty of energy. Certain situations, such as a divorce or illness of other family members can also tax one's ability to cope and may add to a sense of futility or lack of security.
- Support services, interventions and networks provided and available before, during and after the death. Because a child will feel that something is missing following a death it is helpful to have familiar people available to fill the void. Thc child may turn to a trusted counselor or someone else in their immediate network; a coach, a religious teacher. Some children may find it difficult to establish a strong personal connection with someone new. However if they are unable to rely on existing supports, children can be quickly helped by designating a particular individual to fill the role.
Responses: Expected and expressed
We have come to expect certain reactions from children when dealing with death. Their fear, anger, sadness, and guilt are related to their:
- ability to understand the situation
- worry about others' physical and emotional well-being
- desire to protect those who are living
- reactions to changes in home life
- changes in roles and expectations
- feelings of being different, alone, isolated
- sense of injustice
- concern about being taken care of and about the future
Children express their grief by their:
- physical reactions
There are some predictable ways that children understand and respond to death at different ages.
Infants and toddlers: Before age 3
The very young have little understanding of the cause or finality of death, as illustrated by a belief that leaves can be raked up and replaced on a tree. They are most likely to react to separation from a significant person and to the changes in their immediate world. Toddlers are curious about where things go and delight in disappearance and reappearance games such as "peek-a-boo." Their distress at the changes in their environment following a death are displayed by:
- change in sleep and eating habits
Preschoolers and young children: 3-5 years old
With language and learning comes an interest in the world and children this age are full of questions, often repeated. They try to use newly acquired information. A 4-year-old on the plane for the first time looks out the window and asks "We're in heaven -- where are all the people?" They focus on the details of death and may also personalize the experience, perhaps by incorrectly perceiving the cause as stemming from them. For them, being dead can mean living under changed circumstances, so even though a child has seen someone buried underground there may be concern for the person getting hungry. At this age death is equated with punishment. But it is also is seen as reversible; being dead means being still and being alive means moving. When playing cops and robbers, if someone is shot in "play," merely standing up makes you alive once again. Children this age are apt to be sad, angry, scared or worried and communicate these feelings in their:
- tantrums, fighting
- regression to earlier behaviors (such as nightmares, bedwetting, thumb sucking)
- separation fears
- magical thinking that the person can reappear
- acting and talking as if the person is still alive
Early school age children: 6-9 years old
Children this age have the vocabulary and ability to comprehend simple concepts relating to germs and disease. There is still a fascination with concrete details as a way to organize information. When asked what happens when someone dies, a 6-year-old replied, "like a special car comes and it picks them up.a special sort of station wagon what has no back seat on it." 2 They have a sense of the importance of, and contributing factors to, personal health and safety. Yet their emotions and understanding can be incongruent. Therefore we see their less sophisticated beliefs such as in the power of their own thoughts to cause bad things to happen. They also personify death, thinking that a "boogey man" can snatch people away. They are most likely to display:
- fluctuating moods
- earlier behaviors
- school problems such as avoidance, academic difficulty, lack of concentration
Middle school age children: Age 9-12 years old
By age 9 or 10 children have acquired a mature understanding of death. They know that: (1) it is a permanent state; (2) it cannot be reversed; (3) once you have died your body is no longer able to function; (4) it will happen to everyone at some time; (5) it will happen to them. This adult understanding can be accompanied by adult-like responses such as feeling a sense of responsibility, feeling different, being protective of others who have been affected, thinking certain emotions are childish or that they must put up a good front. The most common reactions are:
- isolation, withdrawal
- sleep disturbance
- suppressed emotions
- concern about physical health
- academic problems or decline
Early teens and adolescents
Clearly able to understand the significance of death, teens' responses are directly related to developmental tasks. As they struggle towards independence, they may feel resentful and unsure of themselves, yet pressured to fulfill an adult role. They have a view to the future, question their own mortality, ask themselves "what if?", think about ways life is changed forever, or anticipate events that will be different than imagined such as a graduation or wedding. They may be afraid of exposing their strong feelings and thus they may be denied or ignored and replaced by teenage rebellion. Common reactions include:
- sense of increased responsibility
- risk-taking and acting-out behaviors
- avoidance of feelings
- fear of death
- appetite and sleep changes
- physical complaint
- academic decline or apathy
When to get help
Children and teens are at most risk for adjustment problems in the first year after the loss, with 10-15% at risk for problems, most likely in the form of depression . It is believed that the majority of children and teens have adjusted emotionally and returned to healthy functioning at school, home and with friends at one year. 3 However, some children develop more serious problems that warrant the attention of a mental health professional and some problems may emerge even two or more years later as different developmental tasks or life challenges are confronted. In particular, depending on the child's age and situation and the intensity, frequency, and interference of different symptoms, causes for concern include: 4
- long-term denial and/or avoidance of the topic, lack of recognized response to the loss
- sleep, appetite, weight change and/or disturbance
- extended periods of sadness, loss of interest in activities, feelings of helplessness and hopelessness, inability to experience moments of joy, profound emptiness
- vague and generalized feelings of guilt and depression, rather than sadness connected to the death
- inability to respond to comfort, rejection of support
- purposeful withdrawal from friends, loss of sociability
- inability to sleep, loss of appetite, prolonged fear of being alone
- prolonged rather than transient physical complaints
- acting younger for a prolonged period
- destructive outbursts
- inappropriate euphoria
- inappropriate/illegal behavior
- decline in school performance, refusal to attend school
- persistent anxieties about one's own death or illness
- excessive grief, difficulty weeping or controlling weeping
- acting or imitating the one who has died
- repeated statements about the desire to join the deceased that suggest intent to cause self-injury rather than a just a longing to be reunited
We know that children, as well as adults, grieve in their own way, that feelings change over time, and that the bereavement process goes on throughout life. There can be an ebb and flow to emotions and situations that trigger new thoughts and ways of thinking about the person who has died and one's life without the person. Rather than believe in a set series of stages that one must pass through, the work is conceptualized as different tasks with which one must cope or which one must resolve. The tasks of mourning for children 5 have been modeled on the tasks identified for adults 6 as follows:
- Adults need to accept the reality of the loss. Children need to understand the person has actually died: Understanding can involve believing the death has occurred, understanding the feelings about it, and accepting the accompanying changes. A child may need to accept that dad doesn't braid hair as well as mom or that the family needed to get a new nanny because mom had to start working to earn money after dad died.
- Adults need to work through the pain of grief. Children must also cope with the pain of loss and are faced with future occurrences of feelings related to loss: Experiencing rather than avoiding feelings is a necessary step. Experiencing and facing difficult feelings allows one to manage and move beyond them. As children get older, their understanding and feelings about the person who died may change and these feelings must also be addressed Unaddressed feelings at any time can lead to physical symptoms and emotional difficulties, or exert more force later on. A child may need to tell his mother he will never be as good a baseball player as his older brother who just died.
- Adults adjust to the environment in which the person is no longer there. Children are faced with the task of investing in new relationships and developing a new identity based on the loss: Realization and understanding occurs over time as a death shapes life in new ways. Children face everyday concrete changes in routine as well as changes in responsibilities and role. Coming to terms with the differences encourages active control rather than passive avoidance. Whereas a wife may need to take over the family finances, a teenage boy may need to get a part time job as well as develop a strong bond with a coach as a male role model and guide.
- Adults must emotionally relocate the person who has died to move on. Children accomplish this task by reevaluating the relationship, keeping an internal sense of the person, and continuing on with normal developmental tasks: Gradually, as days and months pass, the intense emotional focus and feelings become less prominent as balance is restored in life and memories are reinforced. There is a re-investment of physical and emotional energy in other aspects of life. This can be seen when a young teen continues to forge strong peer relationships, when a family enjoys a Thanksgiving celebration with talk about happy memories of past holidays, and when children are comforted by realizing they have incorporated qualities of a parent who has died into their own personality or life.
How to help
Children and teens can be helped with coping tasks in a variety of ways. Whereas the particular issues and specific content discussed must be varied and adapted to the age of the child and the situation, it is helpful for parents and adults to: 7
- Tell the truth. The alternative -- hiding information -- causes children to feel confused, unable to turn to adults for help, and mistrustful of other information. Avoid any unnecessary information.
- Be simple and direct. Use correct words and language. Although this may be difficult for adults, saying someone has died is preferable to potentially confusing euphemisms such as "he went to sleep," "he passed on," and "we've lost him."
- Reassure children they are not to blame.
- Model appropriate responses. Do not hide emotions. Explain feelings as a way to help children understand their own, but keep expression of strong, dramatic feelings for private times with other adults.
- Find ways for the child to be involved with family if at all possible. Participating in hospital routines or funeral rituals in whatever way they feel most comfortable can demystify events for children and provides closure.
- Encourage the child to talk and ask questions. Find out what a child thinks and feels and correct any misconceptions or misinformation.
- Become attuned to and respond to the child's own pace for revealing feelings. Offer opportunities for comfort by being available whenever the child/teen is ready or is experiencing some strong emotion.
- Allow and encourage expression in private ways, e.g. use of journals, art.
- Acknowledge and affirm children's expressions. Accept and normalize their response.
- Have more than one conversation. A child's familiarity, interest, and questions about difficult situations change over time. Be available and look for teachable moments or opportunities for further exploration.
- Provide understanding, support, and extra guidance or assistance with school assignments, social obligations, and home chores as necessary over time.
- Explore their feelings about the situation or death. Understand their beliefs and how being confronted with death can stimulate related personal feelings.
- Realize children may make comparisons; they may comment on and wish for things to be the way they used to be, compare times before and after events, compare the surviving parent to the one who has died, or their life to that of others.
- Talk to and enlist the support of other adults (such as teachers and coaches) who are in contact with the children.
- Become familiar with cultural and religious beliefs and practices. Being sensitive to specific rituals and customs is important for understanding how to respond, how to tailor comfort, what is within the realm of expected behavior, and how to prepare and involve classmates.
- Monitor a child's response over time and check out any concerns with a mental health professional.
- Encourage and help the child to collect keepsakes and construct and maintain memories.
About the Author
Robin F. Goodman, Ph.D. , is a clinical psychologist specializing in bereavement issues.
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2. Goodman, RF (1990). Development of the concept of death in children: the cognitive and affective components (Doctoral Dissertation, Adelphi University, 1989). Dissertation Abstracts International . 4405.
3. Christ, GH (1999), Healing Children's Grief . NY: Oxford University Press. Wolfelt, AD (1996). Healing the Bereaved Child . CO: Companion Press.
4. Del Zappo, P.M. (1993) Pastoral Bereavement Counseling: A Training Program for Caregivers in Ministry to the Bereaved . Archdiocese of NY. Weller, RA, Weller, EB, Fristad, MA, Bowes, JM (1991) Depression in recently bereaved prepubertal children. American Journal of Psychiatry , 148 (11), 1536-1540. Wolfelt, AD (1996) op cit.
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7. Goodman, RF (in press). Using art as a component of grief work. In Helping Bereaved Children , Second Edition. NB Webb (Ed.) NY: Guilford. Formanek, R & Gurian, A (1980) Why: Children's Questions . NY: New American Library. 129-133.
About the NYU Child Study Center
The New York University Child Study Center is dedicated to increasing the awareness of child and adolescent psychiatric disorders and improving the research necessary to advance the prevention, identification, and treatment of these disorders on a national scale. The Center offers expert psychiatric services for children, adolescents, young adults, and families with emphasis on early diagnosis and intervention. The Center's mission is to bridge the gap between science and practice, integrating the finest research with patient care and state-of-the-art training utilizing the resources of the New York University School of Medicine. The Child Study Center was founded in 1997 and established as the Department of Child and Adolescent Psychiatry within the NYU School of Medicine in 2006. For more information, please call us at (212) 263-6622 or visit us at www.aboutourkids.org.
Reprinted with the permission of the NYU Child Study Center. © NYU Child Study Center.