Grief and loss in children and adolescents

Overview
Grief is a difficult emotion for everyone -- and can certainly be experienced by children and adolescents as well. Sometimes younger people's grief is overlooked when adults are dealing with their own grief. Remember, however, a child or adolescent may need additional support more than ever when he or she is grieving.
Everyone has a unique time line for grieving. Sometimes children or adolescents wait until the adult caregivers have grieved before they begin their own grieving. Children or adolescents tend to grieve, rest for a while, then begin grieving again. Of course, the relationship and the degree of attachment to the situation or person who has passed away affects the intensity of grief, as well as the young person's age and developmental stage. The nature of the loss -- such as death, divorce, a family move, a disaster or trauma, the development of a chronic condition, the discovery of being adopted, older siblings moving out or the loss of a treasured object -- also plays a role. Sometimes children comprehend the loss only as they realize the implications, such as no longer having holiday dinners at Grandma's house.


Characteristics
At any age, a child or adolescent dealing with grief may sense the distress of the parent or other close adults and how it may affect the emotional atmosphere, which can lead to feelings of insecurity. Common age-specific characteristics are discussed below.
Birth to age 2
A child at this age may experience a sense of loss without understanding what has happened. Because he or she has no knowledge of death, reactions are based on the emotions of others and any separation from the primary caregiver. You may notice a change in crying or eating patterns, irritability, clingy or whiny behavior, bowel or bladder disturbances, or a temporary slowing in development.

Ages 3 to 5
A child at this age may also feel a sense of loss without understanding what has happened. The child may consider death reversible for others but have no concept of death for himself or herself. The child may feel personally responsible for the loss. He or she may want to join the deceased loved one or may appear indifferent to the loss. There may also be literal connections to the loss. For example, if a grandparent died of stomach problems, the child may think, "I will die if I get a stomach ache." If a parent has died, the child may seek reassurance that the surviving parent will not die. The child may ask questions openly, even of strangers.

The child may have headaches, stomach aches or rashes. Periods of sadness may be mixed with normal play. The child may regress to earlier behaviors, such as thumb sucking, clinging, temper tantrums, bedwetting or daytime bladder/bowel accidents. Any fears -- such as fear of the dark, going to sleep (especially if death has been compared to a long sleep), abandoment or being taken away -- may intensify.

Ages 6 to 11
At this age, a child's idea of loss expands. The child knows he or she can die and may fear death or his or her own safety. The child may believe death is contagious or a punishment. The child may alternate between approaching and avoiding feelings. Struggling to relate to peers or teachers can occur. The child may also express anger at a religious leader, God or another higher power, nurses, doctors or anyone who may be perceived as having contributed to the loss. The child may also experience the distress of caregivers and the emotional atmosphere at home.

Ages 12 to 18
Teenagers often believe they're invincible. The teenager may be in denial or view death as a natural enemy. Shock, sadness, anger, guilt and fear are common. A teenager may repress his or her emotions or regress to earlier behavior patterns. He or she may appear cynical ("What difference does it make?") or question or degrade the value of life, asking existential questions such as, "What is the meaning of life?" Physical distress is also a possibility.

Behaviorally, the teen may do poorly in school, abruptly change peer groups, or fight with other kids. Some teens turn to substance abuse or sexual promiscuity. Others run away from home or consider suicide.

Developmentally delayed children or adolescents
A child or adolescent who is developmentally delayed may have tremendous difficulty dealing with loss. He or she may not have the reasoning capability to fully understand the loss or his or her own thoughts or feelings. Anger, guilt, fear and regression are common. The child or adolescent may repress his or her emotions or experience physical distress. The child or adolescent may also fight with other kids.

At any age or developmental level, consider potential signs that a child or adolescent's grief has become more complex and may need additional assistance. For example:

absence of grief (showing no emotion)
persistent blame or guilt
aggressive or destructive outbursts
suicidal thoughts or actions
unwillingness to speak about the deceased
stealing or other illegal acts
displaying addictive behaviors (for example, through drugs or food)
adopting a cynical or callous attitude or devaluing life (for example, "Life sucks, so what's the big deal?")
Sometimes grief can be more than a child or adolescent is able to handle at the time. Symptoms such as sleep disturbances, decreased energy, changes in appetite, anxiety, depression, inability to concentrate and hopelessness may warrant further evaluation by a health care professional.

As with all physical symptoms, consult medical health care provider to rule out a medical condition. If these or any other symptoms cause distress that doesn't seem to improve, seek additional help and support from a mental health care professional.


Coping strategies
Providing comforting objects already familiar to a child or adolescent at any age can be beneficial. Security and stability are important needs during a loss. Also consider the following suggestions for certain age groups:
For children up to age 5, follow routines and maintain consistency as much as possible. Also, play and interact with the child. State the facts and circumstances without lying about death, using simple words the child can understand. Avoid confusing statements, such as "He went away" or "She passed away." Also avoid references to sleeping. Statements such as "She is sleeping" may cause a child to fear going to sleep.

For children ages 6 to 11, talk about what is happening. Plan and participate in a special activity to mark closure on the event. If the child won't be attending the funeral, have him or her make something that can be taken to the service, such as a drawing. Reassure the child that the death of a loved one does not mean the inevitable loss of another. Similarly, a sibling's death does not mean the child will also die young. Define what "dead" means in biological terms and avoid pairing it with abstract concepts, such as an afterlife. On a practical level, notify the child's teacher or other caregivers of what has happened.

For children ages 12 to 18, encourage writing in a journal, drawing, physical activity or another healthy outlet for grief. You may also want to suggest attending a grief support group for teenagers or contacting a counselor or trusted relative or friend.

For children who are developmentally delayed, provide extra reassurance, understanding and patience. Maintain close ranks, and carry on with family rituals and routines as much as possible.

If a move is involved, be aware that the child may become anxious and develop symptoms of depression. His or her friendships and sense of stability may be interrupted. The older the child, the more difficult the move may be due to the increasing importance of peers. Explain to the child why the move is necessary, describe the advantages of the new location and help familiarize the child with the area and its attractions. Consider a closure ritual or activity for the child with old friends, the home, the neighborhood or the area. In the new place, help the child get involved in community activities through the school or a religious organization. Remind the child that he or she can still call, write or e-mail old friends.

If there has been a disaster or trauma, keep in mind that the amount of destruction the child saw or experienced will affect his or her response. Post-traumatic stress disorder, for example, is a natural response to experiencing, witnessing or participating in an overwhelmingly traumatic event. Honor the frightening parts of the disaster with statements such as, "Anyone would have been scared." Listen carefully to the child's account of the trauma and remember that he or she may need to share it several times. Do not minimize the danger -- it will profoundly affect how the child processes the related grief, trauma and loss. Caring adults should remind the child how they're positively coping with the trauma themselves.

Also consider the following additional coping strategies:

When possible, prepare the young person for loss ahead of time. Tell the child or adolescent about any impending loss as soon as possible. Allow the young person to attend the funeral or memorial service, but do not force attendance.

Offer age-appropriate information that's simple, honest and accurate. Expect and address questions and concerns about grief. Pick a time when you can have each other's undivided attention. Take cues from the young person's words, actions and body language about how much information he or she can handle. Recognize that a child may tune out at times in order to protect himself or herself. Be aware that behavior can be a good indication of feelings. Don't try to talk the child out of his or her feelings, and know that the child may look to adults for permission to express those feelings. The child may need to come back to the same information again and again to seek reassurance and make sure the truth is being told.

Acknowledge the changes associated with the loss. Let the young person talk, ask questions and express emotions. Depending on the circumstances, expect questions such as, "Will this happen to me?" and "Is it my fault?" A child who has lost one parent, sibling or other loved one may ask if he or she will lose another. Do not describe death as going to sleep, and be honest and gentle in your responses.

Remind the child or adolescent that there's no timeline for dealing with grief. He or she doesn't have to feel "better" by any particular date and should take as much time as needed. Share your own experiences and coping strategies, keeping in mind that grieving is an individual process.

Don't hide your own grieving. Showing it openly gives the child or adolescent permission to grieve as well. You may want to discuss options for additional support, such as grief support groups or talking with a school counselor, therapist, friend or relative.

Provide comfort. Hold, hug or make eye contact with the child. A stable, secure environment can also be reassuring. Give the young person space, and don't push him or her into anything. You may also want to help the young person establish rituals of remembrance.

Seek additional support through individual, family or group counseling if symptoms intensify or last for a prolonged amount of time. Restrain well-meaning relatives or friends from expressing pity on the child or adolescent though statements such as, "Poor Mike." This sets the stage for long-term self pity and the belief that the child or adolescent is disabled, disadvantaged or does not need to meet normal expectations. Do not ignore any indications that a child or adolescent might be depressed or suicidal. Also, look for books or videos on grief to help the child or adolescent understand the loss and accept his or her own feelings.


Summary
To help a child or adolescent cope with grief, acknowledge his or her feelings and offer as much comfort and support as possible. Although the pain may never go away completely, assure the young person that he or she is not alone and supportive people care.