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Fast Facts and Concept # 138
Grief in Children and Developmental Concepts of Death |
Authors: Adam Himebauch, Robert M Arnold
and Carol May
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 caregiver. 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) -- C hildren 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. Expression 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 are able to 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 and they are interested in 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 in order to more fully challenge their own
mortality. 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..
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, mental health professionals, and others
specializing in bereavement.
References
Gudas LS, Koocher GP. Grief and Bereavement. In: Behrman RE, Kliegman RM,
Jenson HB, eds. Nelson Textbook of Pediatrics, 17 th ed. Philadelphia:
Saunders, 2004:117-120.
Himelstein BP, Hilden JM, Boldt AM, Weissman D. Pediatric Palliative Care.
N Engl J Med. 2004;350:1752-1762.
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. Philadelphia: Mosby, 2000: 547-567.
Fine, P. (Ed). Processes to Optimize Care During the Last Phase of Life.
Vista Care Hospice, Inc. Scottsdale AZ. 1998.
Copyright/Referencing Information: Users are free to download and
distribute Fast Facts for educational purposes only. Citation for
referencing: Himebauch A, Arnold R and May C. Grief in children and
developmental concepts of death. June 2005 End-of- Life Physician
Education Resource Center www.eperc.mcw.edu.
Disclaimer: Fast Facts provide educational information, this information
is not medical advice. Health care providers should exercise their own
independent clinical judgment. Some Fast Fact information cites the use of
a product in dosage, for an indication, or in a manner other than that
recommended in the product labeling. Accordingly, the official prescribing
information should be consulted before any such product is used.
Creation Date: 6/2005
Purpose: Self-Study Guide, Teaching
Audience(s)
Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6,
Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General
Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN,
Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Nurses
ACGME Competencies: Medical Knowledge , Patient Care
Keyword(s): Terminal Care
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