Addressing psychiatric and psychosocial issues related to children and adolescents

Teena M. McGuinness, PhD, CRNP, FAAN, Section Editor

Youth in Mind

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 oth-
ers asserting that infants are capable
of grief. The most common conclu-
sion 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, support-
ing 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 un-
derstand the manifestations of grief at
various developmental stages, to pro-
vide competent support to children of
all ages who experience loss.
pression of grief varies and is depen-
dent 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.
© 2011 iStockphoto.com/Aguru
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 peri-
ods of tears and intense crying for a
few days, but then became quiet and

G
rief is a physical, emotional,
behavioral, and cognitive
response to loss (Worden,
2002). Children of all ages grieve
(Doka, 2000). However, a child’s ex-
INFANTS
Jane is a 12-month-old girl whose
mother developed complications
with a subsequent pregnancy and re-
quired total bed rest. The only viable
apathetic. Three weeks later, when
her mother’s condition improved,
Jane was able to return home. How-
ever, when Jane entered her house,
she appeared indifferent to seeing her

Jocelyn D’Antonio, PhD, PMHCNS-BC, CHPN, CT

Journal of Psychosocial Nursing • Vol. 49, No. 10, 2011 17

Youth in Mind
mother again. Instead, she made her sensorimotor stimulation without
way into her bedroom and curled up concern for spoiling—combined with
on a chair with a blanket and sucked consistent feeding, bathing, and nap-
her thumb. ping schedules—are vital. A grieving
Jane’s behavior exemplifies a grief infant does much better with only
reaction in a very young child. Bowl- one new caregiver, rather than a pro-
by (1980) theorized that infants are gression of several (Hames, 2003).
capable of grief once they develop a
sense of object permanence with the TODDLERS AND PRESCHOOLERS
caregiver, at approximately 6 to 8 Two-year-old Emily and 4-year-old
months of age. Loss of the caregiver, Becky experienced the sudden death
either permanently or temporarily, is of their mother who had an untoward
manifested by protest (crying), de- reaction to anesthesia during a minor
spair, and detachment. If the care- surgical procedure. A month later,
giver does not return after repeated Emily woke up one night crying and
protests over time (or cannot return, terrified, insisting that two rag dolls
as in the death of the caregiver), de- be removed because they frightened
spair develops, followed by detach- her, despite the fact that the dolls
ment. A detached child does not had always been in her room. Becky
The use of books and age-
appropriate literature is an
excellent intervention for
children of all ages, especially
those of school age.
readily re-attach to subsequent care- recurrently played a game with her
givers. Thus, for an infant, the most stuffed animals where a “bad man”
painful emotions associated with takes away the teddy bear and makes
grief include intense feelings of aban- the other stuffed animals left behind
donment and disruptions in forming cry.
future healthy attachments with oth- Emily and Becky’s behavior ex-
ers. Grief in infants is also exhibited emplifies a grief reaction in toddlers
in physical manifestations. Studies of and preschool-aged children. A tod-
infants separated from their mothers dler expresses grief by regressing
and placed in institutions have dem- back to thumb sucking and toileting
onstrated grief reactions that were accidents. They display separation
so extreme as to be life threatening, anxiety, clinginess, and tantrums,
such as failure to grow and thrive along with obvious sadness and
(Norris-Shortle, Young, & Williams, withdrawal (Christ, 2000). A griev-
1993). ing toddler is potentially fearful of
For a grieving infant, abun- the dark and often has sleep distur-
dant love and affection with much bances and nightmares. Although
18
toddlers do not understand death as
adults do, they do know if someone
is missing from their life. Toddlers of-
ten 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 ir-
ritability, regression, stomachaches,
and repetitious questions. They also
experience intense separation anxi-
ety 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 com-
ing back the next. All of this is de-
velopmentally typical and indicative
of their inability to understand the ir-
reversibility (the person cannot come
back), nonfunctionality (the person
cannot eat, play, etc.), and universal-
ity (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 an-
other caregiver. They are sensitive
to strong emotions and to emotion-
al withdrawal from others (Christ,
2000). This can be especially chal-
lenging to a surviving caregiver expe-
riencing his or her own grief (Hames,
2003).
It is all right for a surviving care-
giver to cry in front of the child, but
the reason for the tears should be
explained to the child, if at all pos-
sible, by simply saying that the crying
Copyright © SLACK Incorporated

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 pre-
vents them from drawing false con-
clusions 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 be-
lieve their bad behavior or negative
action was the cause. Their incessant
questions are a developmentally ap-
propriate response, and adults should
listen and patiently answer, even if
the questions sound callous and in-
sensitive 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. Allow-
ing regression with toileting and oth-
er activities and encouraging expres-
sion of feelings through play, dolls,
and art are also important interven-
tions (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, especial-
ly if accompanied by an explanation
such as dead means the deceased par-
ent cannot eat or play anymore. This
helps the child begin to understand
the nonfunctionality of death. At the
same time, reinforcing the permanen-
cy 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 hap-
pen 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 doc-
tor. They might also need reassurance
Journal of Psychosocial Nursing • Vol. 49, No. 10, 2011
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 en-
vironment is expected. Careful analy-
sis and communication is imperative,
and a reasonable alternative is to al-
low 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 expla-
nations 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 dur-
ing 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 chil-
dren. 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. Young-
er children cannot and older children
(adolescents) often will not.
A school-aged child demonstrates
appropriate sadness and anger over
their loss and often experience physi-
cal symptoms such as stomachaches
Youth in Mind
in response to their grief. They de-
pend heavily on their surviving
caregiver and resist separations from
them, even for short periods. Finding
a place for the deceased, like “heav-
en” where the parent is “watching
me,” is not unusual either, nor is us-
ing the deceased’s clothing and oth-
er 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 uncom-
monly makes this request. It is some-
time 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-appropri-
ate literature is an excellent interven-
tion 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 feel-
ings and concerns is another strategy
available to this age group (Scaletti
& Hocking, 2010).
Wolchik, Ma, Tien, Sandler, and
Ayers (2008) found fear of abandon-
ment and coping efficacy to be factors
that mediate the relationship of the
bereaved child with his or her surviv-
ing caregiver and general grief reac-
tions 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 devel-
opmental stage, parental loss is always
traumatic to a child (McClatchy,
19
Youth in Mind
Vonk, & Palardy, 2009). Children
who are offered bereavement sup-
port that includes ongoing informa-
tive discussion and conversation cope
better (Fearnley, 2010). However, the
effectiveness of this support is contin-
gent on the choice of interventions
that are anchored in, and crafted
around, the child’s stage of develop-
ment.
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Dr. D’Antonio is Assistant Professor, School
of Nursing, Long Island University, Brooklyn,
New York.
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.
Address correspondence to Jocelyn
D’Antonio, PhD, PMHCNS-BC, CHPN, CT,
Assistant Professor, School of Nursing, Long
Island University, 1 University Plaza, Brooklyn,
NY 11201; e-mail: jocelyn.dantonio@liu.edu.
Posted: August 17, 2011
doi:10.3928/02793695-20110802-03
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.