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Introduction

At some point, we all face the loss or death of a loved one. This is a difficult experience for a person of any age, but is particularly hard for young people. Adults may be uncertain on how to respond to the needs of children during this time. They might be overwhelmed with their own grief or have questions about how to explain such a difficult concept in ways that children can understand. Even when adults respond the best that they can, a child may still be overwhelmed by grief issues. 

This article describes how children are affected by grief and bereavement, and what family and friends can do to support a grieving child.

Children’s Understanding of Death

Children respond differently to the death of a loved one based on their age and developmental level:

• Age 0-2: Infants and toddlers are unable to understand the concept of death. From their perspective, their loved one (such as a parent) is simply not there anymore, and they react to it the same way that they would to a separation or abandonment by a caregiver. Thus, a child may respond in various ways -- frustration at the change in caregivers, being more clingy to a parent, or through not appearing to care. 
• Age 2-6: Preschool children are beginning to understand the concept of death, but they see death as  reversible  where dead people can come back to life not unlike going to sleep and then waking up. Because they view adults as  powerful, they may also believe that the adult chose to die on purpose. Preschoolers are also self-centered, and as a result, may view death as being about them and think. that it is their fault or that they are being punished for being bad in some way. 
• Age 6-11: School-aged children are able to understand that death is permanent, but may still have troubles understanding why their loved one had to die.
• Age 12+:  Teenagers are capable of fully understanding that death is irreversible, and that it happens to everyone. Despite this however, teens tend to view themselves as invincible, and that death happens to other people. 

How Children Respond to Death

As with adults, children may respond in different ways to the death of a loved one. The loved one may be a person, but can also be a pet. Some of the ways a child may respond include:

• Sadness: The child expresses sadness at the loss, which is the most typical reaction to losing a loved one.
• Anger: Losing a loved one is not fair, and sends the message that the world is an unfair place. This may lead to anger and irritability, which may be directed at themselves or others. 
• Increased anxiety:  Losing their loved one sends the message that the world is a dangerous and unsafe place. As a result, the child may have anxiety and fears about dying and losing other loved ones which may lead to them becoming clingy and afraid to separate from caregiver(s) as a result. 
• Shock/denial: The child is so overwhelmed at the loss that the child tries to avoid facing or dealing with the loss. This may include avoiding talking about the loss.
• Guilt: In some cases, the child may blame him- or herself for the loss. “Maybe if I had been a better child…” “Maybe if I hadn’t told grandma that I hated her that time…”
• Problems functioning at home or school: At school, a child may start having problems with school work while at home a child may be withdrawn and unable to participate in family  activities. A child may also develop behaviour problems and not follow direction from adults.  They may also become aggressive as a way of expressing their anger and sadness. with oppositionality, defiance or aggression. 
• Acceptance: The child accepts the loss and learns to live with it, and is able to go on with his/her life and is able to talk about the loss. 

Do’s

Accept that your child may be more needy and clingy than usual. Ways to support your child's increased needs for connection include:

• Spend more time with your child, preferably 1:1 time. Especially if you have more than one child, it may be hard to find 1:1 time, because the other children tend to be around. However, it may be harder for a child to open up about feelings when others are around, hence the rationale for 1:1 time.

• Provide plenty of physical affection such as plenty of hugs and kisses.

• When your child is faced with a break in your connection (e.g. such as through physical separation when going to school, or going to bed), specifically mention the next time that you will see you child.

• E.g. at bedtime, say the usual statements such as "I love you" but also specifically talk about the next time you will see your child, such as "See you later today, and I can't wait until we go for our walk together."

• The rationale is similar to what we intuitively do when we go on a date with someone. At the end of a successful date, how would you feel if the other person just said, "Goodnight!" and left? You'd feel empty... You feel better if the other person talks about the next time that you'd see each other, e.g. "Goodnight! Let's get together this weekend!"

Tell the child honestly about death so that they can begin to understand that death is final. Avoid euphemisms because young children tend to take things literally.

• E.g. Avoid “Grandpa has gone to sleep” as it may make the child be afraid to go to sleep
• E.g. Avoid “Grandpa has gone on a journey” as it may make the child afraid of journeys.
• Simply say, “Grandpa died.”

Be sensitive to how children understand what you are saying:

• Simply saying “Grandma got sick and she died” can be problematic because then the child will worry about getting sick. Instead, follow-up with “grandma got so sick that nothing could help her, not even the usual medicines”.
• Simply saying, “Grandma went to the hospital and then she died” can be problematic because then your child may be afraid that people who go to the hospital will die. Instead, explain that “Normally people get better in hospital, but grandma was so sick that she died.”
• Use language which is appropriate to the child’s developmental level
  • E.g. Older child: Grandpa had a heart attack
  • E.g. Younger child: Grandpa got so sick that his heart stopped working

Acknowledge and accept the child’s feelings

• Reassure the child that feelings such as shock, disbelief, guilt, sadness and anger are normal feelings
• Do not invalidate the child’s feelings. For example, if a child is sad and upset, don’t say things such as “Don’t be sad.”
• Rather, simply acknowledge the pain and offer support, “Yes, it’s sad. This is tough. I love you and we’ll get through this. Come on, let me give you a hug…”
• Reassure the child that
  • They will always be cared for and loved by an adult
  • That they were not to blame for the death
  • That they  could not have prevented the death
  • That they cannot bring back the person who died

Continue with regular routines as much as possible so that children are able to feel like things are in control.  Continue with family routines and discipline. Although adults may sometimes feel a need to “start fresh”, and make changes after the loss of a loved one (e.g. including moving elsewhere), children generally benefit from consistency and routine. Thus, it is better for the children to continue living in the same neighborhood, going to the same school, and having the same friends and activities. 

Share any religious beliefs about death that you have that will help the child make sense and have meaning of the loss. 

Help the child acknowledge the loss by giving opportunities to talk about the loved one who has died. For example:

• Tell stories about the loved one who died.
• Talk about the positives, e.g.  Caregiver: “What did you like the most about (the deceased person)?"
• Find out what the child misses about the loved one so that you can talk to them about these specific needs, e.g. Caregiver: “What do you miss the most about (the deceased person)?” 
• Explore any negative feelings that the child may have:
  • In cases where children are “stuck” in their grieving process, it may be due to having negative feelings (such as anger or guilt) towards the deceased.
  • Parent: “With people that we care about, sometimes we get upset at them. Anything that you’re upset at (deceased person) about?”

Include children in rituals such as funerals or a memorial service. 

• Most children are able to go to a funeral or memorial. Prepare the child in advance for what is going to happen and be ready to answer questions at the funeral or memorial. If a child does not want to go, ask why, e.g. “What are you worried about?” If the child still doesn’t want to go despite your best efforts, it is best to not force them. 

Read age-appropriate books for children about loss and death..

Accept that grieving does not just occur as a single one time event, but may happen again and again.  

• Even if it seems like a child has successfully grieved a loss, caregivers will have to be aware that the child may need more support later, because as children grow to new developmental stages, they may grieve again. For example: A toddler reacts with frustration at the change in caregivers when her mother dies, but is unable to verbalize the grief. As she grows older, she begins to be able to express her sadness. As a teenager going to graduation, she grieves again that her mother was never able to see her graduate.

Keep in mind that anniversaries can be challenging times when there may be increased feelings of grief. These may include a) a few weeks after the loss when support from others often drops off; b) one year anniversary; c) holidays and birthdays. During these times, check more closely how the child is doing. Normal, healthy activities during anniversary periods might include 1) talking about the loved one, 2) looking at photo albums; 3) going to the cemetery to visit the loved one.Read age-appropriate books for children about grief and bereavement

Frequently Asked Questions (FAQs) from Young People

General Tips for Answering a Question

Before you answer a question, it can help to ask the child, “What makes you ask that question?”

Then, you can directly address your child’s concerns.

After you have answered your child’s questions, check in again with your child, e.g. “Does that answer your question? Any other questions or worries that you have?”

Common Questions

Q. “Will I die?”

A. Possible response from adult: "What makes you ask that?" "Is there a worry you have?" Otherwise, the usual answer: “No, you aren't going to die anytime soon." 

Q. Child: “Who’s going to take care of us if you aren’t around?”

A. Possible response from adult: “Even if something were to happen to us, which is not likely at all, there will always be someone to take care of you. For example, your Aunt Jennifer. Or Uncle Dave.”

Q. Older child: “What is the purpose of life?” “Who am I?” “What’s the point?”

A. With their increased maturity, older children may ask more abstract, philosophical questions. This is an excellent opportunity to have a spiritual discussion about our beliefs about death and what is truly important in our lives. For most people, life is about being connected to people and activities that give a sense of purpose, belonging, hope and meaning.

When to Get Help

It is normal for a child to be sad, experience some anger, anxiety, or guilt, or even have behaviour problems when grieving. Most of the time, your child will grieve and be able to move on.

Is your child having symptoms such as:

• Hopelessness, feeling that life is hopeless;
• Suicide, thinking that life isn’t worth living
• Depressed mood that isn’t going away, along with problems with sleep, appetite, energy and concentration?
• Problems functioning at home, school or work?

If so, then consider seeking other help and supports, which can include:

• Health professionals such as a primary care provider;
• School social worker;
• Grief and bereavement organizations: Many communities have bereaved family organizations that provide monthly meetings, workshops or other activities to support grieving individuals and families.
• Clergy (e.g. hospital chaplain, priest, Rabbi, Imam, etc.)
• School or hospital social worker

When to Get Help

It is normal for a child to be sad, experience some anger, anxiety, or guilt, or even have behaviour problems when grieving.

However, if the child to starts having thoughts of hopelessness or suicide (which may range from thinking that life isn’t worth living, to actively wanting to do things to end his/her life), he or she needs help from a professional. 

If you notice these, then see the child’s family physician, paediatrician, or school social worker for further help.

Community Resources

Grief and bereavement organizations: Many communities have bereaved family organizations that provide monthly meetings, workshops or other activities to support grieving individuals and families.

Clergy (e.g. hospital chaplain, priest, Rabbi, Imam, etc.)

School or hospital social worker

Family physician, paediatrician

Useful Websites

KidsGrief.ca is a free online resource to provide guidance to parents on how to support children who are grieving the dying or death of someone in their life. It equips parents with the words and confidence to help their children grieve losses in healthy ways.
http://kidsgrief.ca

References

American Academy of Paediatrics, The Paediatrician and Childhood Bereavement, Paediatrics, 105(2), Feb 2000, retrieved June 1, 2011 from http://pediatrics.aappublications.org/content/105/2/445.full

About this Document

Written by Dr. Michael Cheng,  Psychiatrist at the Children’s Hospital of Eastern Ontario; Clairneige Motzoi, Clinical Psychologist, Children’s Hospital of Eastern Ontario, and members of the CHEO Mental Health Information Committee  (Corrine Langill, Health Literacy Expert; Michelle Foulkes, Registered Nurse; David Murphy, Child and Youth Counselor; Jennifer Boggett-Carjens, Occupational Therapist; Laura MacLaurin, Nurse; Joanne Doucette, Social Worker; Marla Sullivan, Pharmacist). 

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.

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