The issues surrounding how children understand and respond to death have profound implications for their healthy development into adulthood. Multiple factors influence their cognitive understanding of death, including chronological age and developmental capacity. How well they will cope constructively with losses in childhood is a complex combination of internal and external forces, with important implications for professionals and parents.
Scholarly commentary on children’s understanding of, and reactions to, death reaches back to the 1930s and 1940s, with the publications of Paul Schilder and David Wechsler, Sylvia Anthony, and Maria Nagy. How and when children develop a mature understanding of the finality of death, how their reactions and responses differ from those of adults, and what methodologies best accommodate them in healthy grieving are topics that have received increasing interest in the research and clinical communities in the past 3 decades.



Child’s Understanding of Death

Most discussions of children’s understanding of death begin with the models of childhood development of Erik Erikson or Jean Piaget and the characteristic tasks inherent in subsequent stages of development. It is generally accepted that by the age of 7 years, most children have a mature concept of death. It has long been thought that a mature concept includes the four components of
(1) universality, the fact that everyone dies, that death is the inevitable end to every living being’s life, and that it is unavoidable;
(2) irreversibility, the understanding that once you are dead, you cannot come back to life;
(3) nonfunctionality, that when people die they can no longer engage in biological activities like eating, talking, breathing, walking, or laughing; and
(4) causality, that death happens because of certain and identifiable biological reasons.

More recently, two additional concepts have been proposed, by Lynne Ann DeSpelder and Albert Lee Strickland, and Mark W. Speece and Sandor B. Brent, respectively. Those concepts are
(5) personal mortality, the realization that “I will die too,” and
(6) noncorporeal continuation, the nonempirical notion of some kind of existence beyond the physical.

From birth to approximately 2 years of age, corresponding to the sensorimotor period in Piaget’s model of cognitive development, the child is developing senses and motor abilities and begins to build bonds with what John Bowlby referred to as the “mother-figure.” Pioneering work on loss and attachment by John Bowlby and others about infancy and abandonment laid the groundwork for a clearer understanding of how deeply infants and very young children understand, if not death, at least goneness.
Piaget’s preoperational period includes ages 2 to 4, a time of intense egocentric thought, and ages 4 to 6, when more socialization, speech development, and problem-solving abilities develop. During this time many children become curious about and interested in death, through the experience of insects and animals, cartoons and children’s books, or the deaths of pets or grandparents. While struggling with a comprehensive understanding of the finality of death, it is not unusual for children this age to engage in “magical thinking,” that is, the belief that their actions contribute directly to events that objectively they cannot control. They may believe they “caused” someone to go away and, subsequently, that they can “cause” the person to return.
Around the age of 7 through age 12, during what Piaget calls the concrete operational period, children’s understanding of the death concepts is generally mature, though the operational tasks of this age provide a challenging time for incorporating the death of a parent or sibling into the normal growth experiences of building competency, comparing oneself to others, and valuing peer relationships. Finally, entering the formal operational period at age 12, the adolescent’s tasks and challenges of individuation and independence emerge in force, and peer relationships take on primary concern in the child’s world. It is important to remember that coping with the death of a person who had a primary relationship with a child or adolescent — a parent, sibling, or close friend — is not an event but rather a process. The grief will be re-experienced throughout the phases and periods of the child’s development and well into adulthood, when the early loss of a parent may become acutely experienced through pivotal events like graduation and other successes, dating, marriage, raising one’s own children, and turning the age of the person who died.

Influences on Children’s Reactions to Death

In addition to the child’s developmental and chronological age and capacity for understanding a mature concept of death, other issues will influence how children respond to death. An important influence is the social context in which a death takes place. Bill Worden and Phyllis Silverman, in the Harvard Children’s Bereavement Study results, emphasize that after a parent’s death, one of the strongest predictors of how a child will cope is the emotional and mental health of the surviving parent. Other social factors influencing the child include what other support systems are available; how friends and peers respond; and what level of social engagement, belonging, and competence the child has through athletics, clubs, religious affiliations, and other activities.
The preexisting relationship of the child to the deceased is an important and often underemphasized aspect of how a child will cope. If the relationship was conflictual, death does not resolve the conflict; if the last communication between the deceased and the child was problematic, the possibility of resolving
the relationship strain is no longer viable; and often, at all ages, children and adolescents often continue to believe that their behavior in some way
contributed to the death. In cases where the child’s actions contributed to the death, through an accidental shooting, for example, the normal complications
of grieving may be exacerbated.
Other possible complications to how children may respond include witnessing the death, facing the stigma of suicide or violent death, dealing with the absence of a body, and all of the secondary losses that may accompany such a loss. These may include changes like moving to a new home, losing friends, questioning prior beliefs about God and the nature of one’s personal safety, divorce, and shifting to a new school, among others.

Children’s Versus Adults’ Grief Reactions

Typical, normal responses to grief include emotional, physical, spiritual, relational, and psychological aspects. Emotions may include sadness, anger, relief, frustration, rage, guilt, and the full range of expression or repression of these, in accordance with the child’s personality, intelligence, experience, and developmental age. Often young children in grief show regressive behaviors like bedwetting, crying when left, returning to wanting a bottle, or wanting to be held like a baby, though these effects typically decrease with time. Physical manifestations may include headaches, stomachaches, pains or aches for which no physical cause may be found, difficulties sleeping or eating, and conversely, overeating and oversleeping, as well as difficulty concentrating, staying focused, and attending to tasks. The experience of grieving may be isolating as adolescents withdraw from friends who don’t understand or don’t provide helpful consolation, and they often challenge and question assumptions made about personal safety, the meaning of life, and the existence of a benevolent God.
In a society that urges grievers to “move on” or “get over” grief, children’s and adolescents’ need for memorialization, meaning-making, and continuing bonds with the deceased are often overlooked by the adults around them. Additionally, growing professional interest in pathologizing the experience of grief has led to unrealistic expectations of the expected duration and intensity of grief symptoms, particularly among youth. Whereas models for how adults grieve have proliferated and include tasks of grieving, phases of grieving, as well as Elisabeth Kübler-Ross’s much abused and overgeneralized notion of “stages of grief,” models of how children grieve have relied, for the most part, on the developmental stages and periods of Piaget and Erikson discussed earlier. As a result, there has been a lesser understanding of the differences between how children grieve and how adults grieve.
Because children’s expressions of grief are so intertwined with their understanding of death and their continuing developmental processes, integrating death into their lives appears to be an ongoing process, hence longer in duration than that of most adults. Additionally, children have less life experience and more limited developed means to make sense of death and often fewer tools with which to express themselves. They tend to be more sporadic in their grief responses than adults — that is, seemingly in and out of the intensity of feeling, one minute crying and the next wanting to join friends for a basketball game.

Parental Death

More research has been conducted on the impact of parent death on children than sibling or friend death, most likely because it is more commonly experienced. Most studies have been retrospective, and there is a wide range of research and practice-informed literature addressing the effect of early parental death. Because of the variety of factors influencing how children may respond to a parent’s death as discussed above, it is impossible to conclude that all parentally bereaved children will suffer traumatic consequences as a result of the death. Numerous studies, however, refer to parentally bereaved children’s increased vulnerability for risk of depression, anxiety, and relationship issues, among other symptoms. Conversely, psychologists like Richard Tedeschi and Lawrence Calhoun, who coined the term post-traumatic growth in 1995, point out opportunities for growth even among the most potentially traumatizing of events.

Sibling Death

Although the occurrence of sibling death in childhood is less frequent than that of parental death, and much less research has been conducted on the potential longer-term outcomes, it is generally agreed that the death of a sibling may bear a significant impact on surviving siblings. As with parental death, the response of the surviving parents is a pivotal influence on the surviving child or children. One aspect of sibling death that often heightens, as opposed to parental death, is the frequent sense of guilt among children that they were permitted to live while the sibling was not. Betty Davies has studied and written extensively about the long-term effects of sibling deaths in childhood.

What Children Need

In 1980 John Bowlby proposed four factors that facilitate a child’s ability to mourn, and though they have been further expanded by clinicians throughout the years since, they remain a solid foundation from which to understand how to best assist children following a death.
The first factor, and the only one that cannot be retroactively controlled, is having a secure relationship with parents before the death occurs.
Children who have experienced multiple losses, including divorce or abandonment, or whose lives include substance abuse, violence, physical abuse, and instability, stand at greater risk for future difficulties without that solid foundation of security, love, and support with which to manage living in the wake of death.
Second, Bowlby advocated that children fare better when they receive prompt and accurate information about the death. Often in an effort to “protect” children, adults do not share information honestly, especially if the death is a stigmatized death like suicide, AIDS related, or homicide. Children frequently attune to the reality that the truth is being withheld, they intuit from others that the story they have is not the full one, and/or they hear through other children or the media about the actual circumstances of the death. For these reasons, and because having the truth and not having to “fill in the blanks” allows children to begin to regain a sense of personal control, they should be told the truth by a trusted adult, as soon as possible, in ways that are developmentally appropriate and in language they can understand.
Participation in the social rituals around the memorialization of the life and disposition of the body of the deceased is the third factor that facilitates
a child’s ability to mourn. Because a death inherently changes the lives of those mourning the loss of the person, having choices around designing and participating in rituals such as casket selection, funeral or memorial rituals, and where and how the body will be disposed help children feel a part of, rather than excluded from, these social networks and decisions.
Finally, Bowlby’s fourth factor is having the comforting presence of a parent or parent substitute after the death. Studies of resiliency and children frequently refer to the importance of adult parentfigures or mentors in the lives of at-risk youth.
Robert Neimeyer, Daniel Siegel, David Crenshaw, and others have more recently placed emphasis on the healing power of meaning-making, in which children are supported in developing coherent narratives around what happened, and the meaning they derive from their experiences following a loss through death. An additional aspect of the meaning-making is the reality that change occurs in a social context; that is, our neurobiology is affected through the interchange with others.

Normal Reactions Versus Trauma/PTSD

Considerable focus by researchers and clinicians in the early 2000s has centered on the issue of trauma and post-traumatic stress disorder (PTSD). The diagnostic criteria refer to symptoms emerging from emotionally traumatic experiences, with three main clusters: intrusive and unwanted flashbacks or nightmares, in which the traumatic event is reexperienced; avoidance, such as when the person actively avoids exposure to people, places, or things that might trigger intrusive symptoms; and hyperarousal, evidenced as increased physiological arousal such as hypervigilance or a trigger-pin startle response. While it is generally accepted that early traumatic experiences may have long-term consequences, there is less clarity on what defines a traumatic experience. For example, some children exposed to violent deaths, suicide deaths, and/or other seemingly traumatic events may not show symptoms of PTSD or trauma, indicating that it is not the event itself, but rather, the perception and meaning-making of the event that engenders trauma symptoms. Judith Cohen and Anthony Mannarino coined the term childhood traumatic grief to describe the condition in which trauma symptoms interfere with a child’s ability to engage in a normal grieving process, and this model implies the need for professional intervention to address the trauma aspect and symptoms and reduce the risk of future psychopathology. More research is needed to determine under what circumstances children experiencing loss through death may develop trauma symptoms, as well as the evidence for effective treatment models.

Research and Interventions

Increasing interest in possible long-term effects of unaddressed childhood grief has led to widely disparate stances on the efficacy of therapeutic interventions. In the early 1980s a burgeoning number of children’s grief support programs developed, now numbering in the hundreds, networked through the National Alliance for Grieving Children. Significant contributions to the field of knowledge have been developed through the research of Phyllis Silverman and J. William Worden, Irwin Sandler and researchers at the University of Arizona, among others. Much more research, however, remains to be conducted, particularly on intervention methods. In a meta-analytic review of controlled outcome research in 2007, Joseph Currier, Jason Holland, and Robert Neimeyer were able to locate only 13 studies that included a control group and quantitative measures. One of the major obstacles to research is the lack of a well-validated measure of childhood grief.

(c) Donna L. Schuurman