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Children at different developmental stages grieve differently than adults. It is important to adjust grief interventions as well as death attitude discussions to the correct developmental phase of the child to achieve highest possible efficacy. In children, grief may manifest itself through somatic symptoms (sleep difficulties, poor appetite, bedwetting, headaches and other physical complaints), psychological symptoms (distress, separation anxiety, fear of death for other loved ones, guilt, depression, attention deficit), and behavioral symptoms (regression, temper tantrums, loss of interest in usual activities, overdependence, seeking attention, extreme shyness). Children are also known to re-experience grief as they reach new developmental phase and their understanding of the events and the contributing factors change. Presence of a significant adult in the life of the grieving child and the safe feeling of being in a physically and emotionally stable environment are the major factors helping children to overcome grief. Children may also find it useful to maintain a mental connection with the person who has died, forming a bond, which helps them deal with their grief and get over the loss. Several stages of development in children are known to be associated with specific death attitudes and reactions to the terminal illness or loss of a loved one.
1. Infants (up to 2 years old) have not yet formed an understanding of death, however, separation from a significant person in their life may cause grief and anxiety. In severe cases infants may go through temporary behavioral and developmental regression. Infants at this age will also be impacted by grief and distress of their caregiver and may cry feeling sadness or nervousness of their caregiver. Interventions to protect infants from distress include maintaining routines and avoiding separation from other significant persons in the infant’s life.
2. Preschool children (2-6 years old) at this age see death as only temporary and reversible. Their perception of life is half real/half fairy tale, thus, children at this age may have a magical explanation to death, or may believe that their bad thoughts or behavior killed their loved one. Feeling guilty is very common. If intervention is necessary it is important to address and correct misperceptions. It is important to explain to them that the loved one who passed away is not coming back.
3. School age children (6–8 years old) at this age begin to understand that death is final, permanent, and irreversible, however do not consider death universal or applicable to themselves. Children at this age may express anger towards the deceased or towards those individuals, who they consider guilty of not saving the deceased. Grief may be manifested through anxiety, depressive symptoms, and somatic complaints. The child may get preoccupied with fear of death and safety concerns. Interventions should include provision of clear, realistic information. Children may be offered to participate in the funeral ceremony. School must be notified to help teachers monitor the child and cooperate in providing support.
4. Pre-adolescents (8–12 years old) at this age develop an adult understanding of death. This understanding implies that death is irreversible, final, and universal for all the living creatures. Pre-adolescents begin to understand the biological aspects and causes of death. However, dealing with feelings is very difficult at this age. The normal curiosity will attract their attention to the physical details of dying, in how adults view and react to death, in cultural traditions and rituals following death. Often, pre-adolescents will experience feelings of guilt. In intervention, it is important to identify if guilt is present and address that. To help the child identify and share emotions, it will help to talk about your own emotions and ask the child to share his/her views or feelings. If the child expresses a wish to see the dying patient or to participate in the funeral ceremony, he/she should be allowed to do so, provided the adult takes additional time to share and discuss emotions, feelings, and experiences.
5. Adolescents (12–18 years old) Adolescents understand death as adults. Within their developmental pattern, adolescents fight for their independence, question the norms and rituals, and feel they are not understood by the adults in their life. Adolescents question existential beliefs of death and may engage in high risk activities in an effort to challenge their own mortality. Although they have strong emotional reactions to death and loss, they usually have difficulty sharing feelings. Interventions in adolescence must support independence and strengthening of social ties with classmates and friends, however also be ready to provide emotional support when necessary.