Grief and Loss of a Caregiver in Children: A Developmental Perspective

Abstract

Grief is one's response to loss. Each person's expression of grief is unique and influenced by factors such as age, culture, and previous exposure to loss. Whether or not children grieve has been debated, with some proponents stating that children do not grieve at all until they are adolescents, and others asserting that infants are capable of grief. The most common conclusion is that children of all ages do grieve, although their grief is different from that of adults. Children's grief is also closely related to developmental stage, so children of varying ages also grieve differently. Therefore, supporting a grieving child is relative to his or her stage of development. For this reason, it is important for practitioners working with grieving children to understand the manifestations of grief at various developmental stages, to provide competent support to children of all ages who experience loss.

Grief is a physical, emotional, behavioral, and cognitive response to loss (^{Worden, 2002} ). Children of all ages grieve (^{Doka, 2000} ). However, a child's expression of grief varies and is dependent on developmental age (^{Hunter & Smith, 2008} ). An understanding of the relationship between and age and manifestations of grief in children is crucial for practitioners to provide effective interventions to a grieving child. In the vignettes that follow, all names as pseudonyms.

Infants

Jane is a 12-month-old girl whose mother developed complications with a subsequent pregnancy and required total bed rest. The only viable option was for Jane to be cared for by an aunt and uncle whom she had met only a few times and who lived in a neighboring state. When the aunt and uncle came to pick her up, Jane protested and cried heartily as she was carried away from her mother to the car. She continued to have periods of tears and intense crying for a few days, but then became quiet and apathetic. Three weeks later, when her mother's condition improved, Jane was able to return home. However, when Jane entered her house, she appeared indifferent to seeing her mother again. Instead, she made her way into her bedroom and curled up on a chair with a blanket and sucked her thumb.

Jane's behavior exemplifies a grief reaction in a very young child. Bowlby (¹⁹⁸⁰ ) theorized that infants are capable of grief once they develop a sense of object permanence with the caregiver, at approximately 6 to 8 months of age. Loss of the caregiver, either permanently or temporarily, is manifested by protest (crying), despair, and detachment. If the caregiver does not return after repeated protests over time (or cannot return, as in the death of the caregiver), despair develops, followed by detachment. A detached child does not readily re-attach to subsequent caregivers. Thus, for an infant, the most painful emotions associated with grief include intense feelings of abandonment and disruptions in forming future healthy attachments with others. Grief in infants is also exhibited in physical manifestations. Studies of infants separated from their mothers and placed in institutions have demonstrated grief reactions that were so extreme as to be life threatening, such as failure to grow and thrive (^{Norris-Shortle, Young, & Williams, 1993} ).

For a grieving infant, abundant love and affection with much sensorimotor stimulation without concern for spoiling--combined with consistent feeding, bathing, and napping schedules--are vital. A grieving infant does much better with only one new caregiver, rather than a progression of several (^{Hames, 2003} ).

Toddlers and Preschoolers

Two-year-old Emily and 4-year-old Becky experienced the sudden death of their mother who had an untoward reaction to anesthesia during a minor surgical procedure. A month later, Emily woke up one night crying and terrified, insisting that two rag dolls be removed because they frightened her, despite the fact that the dolls had always been in her room. Becky recurrently played a game with her stuffed animals where a "bad man" takes away the teddy bear and makes the other stuffed animals left behind cry.

Emily and Becky's behavior exemplifies a grief reaction in toddlers and preschool-aged children. A toddler expresses grief by regressing back to thumb sucking and toileting accidents. They display separation anxiety, clinginess, and tantrums, along with obvious sadness and withdrawal (^{Christ, 2000} ). A grieving toddler is potentially fearful of the dark and often has sleep disturbances and nightmares. Although toddlers do not understand death as adults do, they do know if someone is missing from their life. Toddlers often feel they have caused the sadness and grief they sense in others around them and lack the necessary verbal skills to understand that this is not so (^{Hames, 2003} ). A toddler's grief is short lived, sporadic, and specific to the situation. It is likely to re-emerge in different forms, with each ensuing developmental stage (^{Christ, 2000} ). Typically, a child of this age may be happy and well one minute and then angry and regressed the next (^{Stuber & Mesrkhani, 2001} ).

Preschool-aged children are more likely to express their grief with irritability, regression, stomachaches, and repetitious questions. They also experience intense separation anxiety and express it in play and fantasy. They may ask for a "replacement" parent several months later. This is an age-appropriate behavior that may seem insensitive and callous to an uninformed adult. A preschooler can verbally acknowledge that they know the loved one is dead one minute, but then ask when the deceased is coming back the next. All of this is developmentally typical and indicative of their inability to understand the irreversibility (the person cannot come back), nonfunctionality (the person cannot eat, play, etc.), and universality (it happens to everyone) of death (^{Christ, 2000} ).

Children younger than 5 who have experienced the loss of a parent need a consistent caring presence from another caregiver. They are sensitive to strong emotions and to emotional withdrawal from others (^{Christ, 2000} ). This can be especially challenging to a surviving caregiver experiencing his or her own grief (^{Hames, 2003} ).

It is all right for a surviving caregiver to cry in front of the child, but the reason for the tears should be explained to the child, if at all possible, by simply saying that the crying and sadness is because the deceased will never be seen anymore. It is best not to wail, but if this is the cultural norm, then an explanation to the child is even more necessary. Hiding grief is not wise, since children sense it anyhow, and a direct approach prevents them from drawing false conclusions about its cause. It is vital to constantly assure young children that they did not cause the death or grief, as it is very common for them to believe their bad behavior or negative action was the cause. Their incessant questions are a developmentally appropriate response, and adults should listen and patiently answer, even if the questions sound callous and insensitive to an adult's ears. It is also important to tell preschoolers what they need to be told in small amounts and in familiar surroundings. Allowing regression with toileting and other activities and encouraging expression of feelings through play, dolls, and art are also important interventions (^{Norris-Shortle et al., 1993} ).

Euphemisms and abstractions are not advisable. Telling a child that the deceased is "sleeping" could cause the child to fear going to bed. It is best to use the terms dead and death, especially if accompanied by an explanation such as dead means the deceased parent cannot eat or play anymore. This helps the child begin to understand the nonfunctionality of death. At the same time, reinforcing the permanency of death can be included, since this is also an aspect of death that children at this age do not grasp. Providing a physical reason for the death, such as "their heart stopped working" and adding that this cannot happen to the child because his or her heart is not sick, is also advisable, as children can wonder if the same thing could happen to them (^{Hames, 2003} ). A child should be reassured that they cannot "catch" what the deceased had and that most illnesses are not serious, so they will not fear going to the doctor. They might also need reassurance that others in their lives will not die as well and that there will always be someone to care for them. The best way to provide information is in small amounts and in a proactive manner, so the sharing of information is not solely reactive and tied into moods and signals from the child (^{Stuber & Mesrkhani, 2001} ).

A decision to bring a child of this age to the funeral should be made sensitively on an individual basis. Leaving the child at home can add to any existing feelings of abandonment, whereas attending the funeral can be upsetting if an intense emotional environment is expected. Careful analysis and communication is imperative, and a reasonable alternative is to allow the child to attend the funeral but assign a friend or family member who is not directly affected by the death to sit with the child and provide explanations as needed and then remove the child if the service is too long or uncomfortable (^{Hames, 2003} ).

School-Aged Children

Since his father's death 3 months ago, 9-year-old Matthew loves to put on a hat that was his father's, curl up in a chair with his mother, and have her read some of the books his father used to read to him. Sometimes during these sessions, Matthew tells his mother that he thinks his father is watching down on them or asks her questions about where people go when they die.

Matthew's behavior exemplifies a grief reaction in school-aged children. A school-aged child who has lost a parent or other close person has an advantage over younger children in more advanced language skills. It is the one age group most able to speak openly about death and dying. Younger children cannot and older children (adolescents) often will not.

A school-aged child demonstrates appropriate sadness and anger over their loss and often experience physical symptoms such as stomachaches in response to their grief. They depend heavily on their surviving caregiver and resist separations from them, even for short periods. Finding a place for the deceased, like "heaven" where the parent is "watching me," is not unusual either, nor is using the deceased's clothing and other personal items in their play. Like a preschooler, a 6 to 8 year old may eventually request a "replacement" parent, but a 9 to 11 year old uncommonly makes this request. It is sometime during these years that a child develops the ability to understand the irreversibility, nonfunctionality, and universality of death (^{Christ, 2000} ).

The use of books and age-appropriate literature is an excellent intervention for children of all ages, especially those of school age. The characters in stories can provide bereaved children with role models of children who are coping with loss. In addition, when reading together, adults can gain valuable insight into the thoughts and feelings of a bereaved child (^{Corr, 2009} ). Music therapy and brief school-based grief counseling are two other interventions that can be used in this age group (^{Rosner, Kruse, & Hagl, 2010} ). Focused storytelling that seeks to draw out grief-related feelings and concerns is another strategy available to this age group (^{Scaletti & Hocking, 2010} ).

Wolchik, Ma, Tien, Sandler, and Ayers (²⁰⁰⁸ ) found fear of abandonment and coping efficacy to be factors that mediate the relationship of the bereaved child with his or her surviving caregiver and general grief reactions in this age group. Therefore, it is important to support children of this age in their desire to remain close to the surviving caregiver while enhancing independence as much as possible.

Conclusion

No matter what the child's developmental stage, parental loss is always traumatic to a child (^{McClatchy, Vonk, & Palardy, 2009} ). Children who are offered bereavement support that includes ongoing informative discussion and conversation cope better (^{Fearnley, 2010} ). However, the effectiveness of this support is contingent on the choice of interventions that are anchored in, and crafted around, the child's stage of development.

Footnote

The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

References

Bowlby J , (1980). Attachment and loss: Vol. III. Loss, sadness, and depression. New York: Basic Books.

Christ G H , (2000). Impact of development on children's mourning. Cancer Practice, 8, 72--81. 10.1046/j.1523-5394.2000.82005.x

Corr C A , (2009). Siblings and child friends in death-related literature for children. Omega, 59, 51--68. 10.2190/OM.59.1.d

Doka K J, (Ed.). (2000). Living with grief: Children, adolescents, and loss. Levittown, PA: Brunner/Mazel.

Fearnley R , (2010). Death of a parent and the children's experience: Don't ignore the elephant in the room. Journal of Interprofessional Care, 24, 450--459. 10.3109/13561820903274871

Hames C C , (2003). Helping infants and toddlers when a family member dies. Journal of Hospice and Palliative Nursing, 5, 103--110. 10.1097/00129191-200304000-00016

Hunter S B , Smith D E , (2008). Predictors of children's understandings of death: Age, cognitive ability, death experience, and maternal communicative competence. Omega, 57, 143--162.

McClatchy I S , Vonk M E , Palardy G , (2009). The prevalence of childhood traumatic grief--A comparison of violent/sudden and expected loss. Omega, 59, 305--323.

Norris-Shortle C , Young P A , Williams M A , (1993). Understanding death and grief for children three and younger. Social Work, 38, 736--742.

Rosner R , Kruse J , Hagl M , (2010). A meta-analysis of interventions for bereaved children and adolescents. Death Studies, 34, 99--136. 10.1080/07481180903492422

Scaletti R , Hocking C , (2010). Healing through story telling: An integrated approach for children experiencing grief and loss. New Zealand Journal of Occupational Therapy, 57, 66--71.

Stuber M L , Mesrkhani V H , (2001). "What do we tell the children?": Understanding childhood grief. Western Journal of Medicine, 174, 187--191. 10.1136/ewjm.174.3.187

Wolchik S A , Ma Y , Tien J Y , Sandler I N , Ayers T S , (2008). Parentally bereaved children's grief: Self-system beliefs as mediators of the relations between grief and stressors and caregiver-child relationship quality. Death Studies, 32, 597--620. 10.1080/07481180802215551

Worden J W , (2002). Grief counseling and grief therapy: A handbook for the mental health practitioner (3rd ed.). New York: Springer.