Addressing psychiatric and psychosocial issues related to children and adolescentsTeena M.

McGuinness, PhD, CRNP, FAAN, Section

Editor Youth in Mind

Grief and Loss of a Caregiver in Children

A Developmental Perspective
ABSTRACT rief is a physical, emotional, the vignettes that follow, all names as
Grief is one’s response to loss. Each
person’s expression of grief is unique
and influenced by factors such as age,
G behavioral, and cognitive pseudonyms.

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.
response to loss (Worden, 2002). INFANTS
For this reason, it is important for Children of all ages grieve Jane is a 12-month-old girl whose
practitioners working with grieving (Doka, 2000). However, a child’s mother developed complications with a
children to understand the expression of grief varies and is subsequent pregnancy and required total
manifestations of grief at various dependent on developmental age bed rest. The only viable option was for

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

Journal of Psychosocial nursing • Vol. 49, no. 10, 2011 17

developmental stages, to provide
competent support to children of all
ages who experience loss.
(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
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
Youth in Mind
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
Journal of Psychosocial nursing • Vol. 49, no. 10, 2011
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
18
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
Copyright © SLACK Incorporated
 Youth in Mind

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).
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
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,
19
Youth in Mind
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. REFERENCES
Bowlby, J. (1980). Attachment and loss: Vol. III. The author discloses that she has no significant
Loss, sadness, and depression. New York: financial interests in any product or class of
Basic Books. products discussed directly or indirectly in this
Christ, G.H. (2000). Impact of development on activity, including research support.
children’s mourning. Cancer Practice, 8, 72- Address correspondence to Jocelyn D’Antonio,
81. PhD, PMHCNS-BC, CHPN, CT, Assistant Professor,
Corr, C.A. (2009). Siblings and child friends in School of Nursing, Long Island University, 1
death-related literature for children. University Plaza, Brooklyn, NY 11201; e-mail:
Omega, 59, 51-68. doi:10.2190/OM.59.1.d jocelyn.dantonio@liu.edu. Posted: August 17,
Doka, K.J. (Ed.). (2000). Living with grief: 2011 doi:10.3928/02793695-20110802-03
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.
doi: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.
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,
305323.
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.
doi: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.
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.
doi:10.1080/07481180802215551
Worden, J.W. (2002). Grief counseling and grief
therapy: A handbook for the mental health
practitioner (3rd ed.). New York: Springer.

Dr. D’Antonio is Assistant Professor, School of

Nursing, Long Island University, Brooklyn, New
York.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.