Dr. Elizabeth Kubler Ross made tremendous contributions in the area of death and dying. With regards to grief once someone dies, stages have not been a helpful concept. We know that feelings of grief evolve over time rather than being linear. Early on, the concept of stages was developed with those who were terminally ill, in the process of dying. Unfortunately, people who are grieving have applied them to their experience. This caused the bereaved to think they "must" go through the stages and that something is wrong if they do not experience them all or complete them. Grief is now seen as more fluid with individuals actively integrating the experience and the loss and death of the person over a lifetime. For children in particular, it has been more useful to focus on 4 tasks identified by William Worden (Worden, JW. Grief counseling and grief therapy: A handbook for the mental health practitioner. fifth ed. New York: Springer Publishing Company; 2018), https://www.amazon.com/Grief-Counseling-Therapy-Fifth-Practitioner-dp-0826134742/dp/0826134742/ref=dp_ob_title_bk.

The tasks include: Task 1: "Accept the reality of the loss". It can be helpful to view this as acknowledging the death and knowing the person will not come back. With children, keeping in mind their age impacts the ability to fully understand the finality of the death. Task 2: "Process the pain of grief". For a child, this can mean experiencing, understanding, and learning how to manage different emotions. The process can include multiple, complex, or ambivalent feelings about the person as well. Task 3: "Adjust to a world without the deceased". This can involve adjusting to one's sense of self, how the world is now different, and what has changed in other areas such as relationships and beliefs about the world. A part of this process can be about allowing new people to enter one's life. Task 4: "Help the survivors find an appropriate place for the deceased in their emotional life". Although the person does not come back, it is possible to still honour them, have a relationship via memories, have feelings about how they continue to be an influence, and find meaning in the grief experience throughout life.

The death of a special person for a child is a permanent loss, but their understanding, feelings, and reactions vary according to their age and will evolve over time. It is important to realize that a child may revisit certain issues or have new questions as they get older and are at a new stage in their life. The following are some general guidelines about what to expect.

Infants and toddlers do not know the meaning of death, but they do respond to the changes in their environment, who is caring for them, and stress of those around them. Their upset can be seen in their crying, change in sleeping and eating, and regression in behaviors such as bed-wetting or thumb sucking.

Pre-schoolers and young children (age 3-5) with their developing minds do not yet understand that death is final. They can believe it is reversible or that the person is still alive in a different way. This explains their wondering if the person is hungry. They may simplistically associate being still with being asleep and think the person will wake up. They also may connect it to violence or accidents, having less ability to understand a body stops working. It is normal for them to ask when the person is coming back even though they were told the person died. It is not because they forgot. Due to magical thinking and less mature cognitive ability, they can think the person will return. Their play may give clues to their feelings and reactions. Irritability, being afraid to be away from caregivers, as well as fighting, crying, and regression can be an expression of the mix of feelings. This can alternate with usual play.

Young school-age children’s (age 6-9) understanding is personalized and based on simple concepts of cause and effect. They may associate death with being bad or punished and may think they did something wrong to cause it. They can incorrectly believe their thoughts could have made the person die. For example, being mad at a sibling and wishing they were not here led to the death. At this age, their imagination may have them believe other beings, such as ghosts and spirits are responsible for death. Their feelings may be revealed by physical symptoms (e.g., stomach aches) or worries about being away from home, yet their emotions and reactions can also go back and forth, being sad for a time but then being engaged in familiar fun activities.

Older school-age children (age 9-12) by nine or ten have a mature understanding of the main concepts of death: that it is permanent, it is irreversible, and you can’t make the person come back, it is inevitable and will happen to everyone everywhere, and the body stops functioning. Children at this age may worry if something was contagious or be interested in details about the cause. They can feel guilty that things they said or did caused the person to die and have fears related to understanding that death is possible for themselves and others. Their feelings may go underground, and they can be sensitive to feeling different from peers.

Teens have a complete adult understanding of death. Although they can know thoughts did not cause the death, they may blame themselves, for example, for causing stress that impacted the person, such as believing fights about homework caused a heart attack. Or they feel guilty for harsh words or tension existing before the person died and wish it had been different. They may feel an added sense of responsibility or that things are out of their control and be more reckless because death is inevitable. On the other hand, some will think about their purpose in life and place in the world and what the person would have wanted for them.

In addition to their ability to understand death, children’s feelings and reactions can vary due to their age. Common reactions include feeling sad, confused, helpless, lonely, isolated, worried, anxious, guilty, or angry, and they may withdraw or act out. This can result in difficulty concentrating in school or being with others. These reactions may be expressed differently based on age. For example, a 4-year-old may exhibit temper tantrums and regress, whereas a teen may act out with angry outbursts or risky behavior. Worry in a young child may be seen by their having trouble sleeping alone, and a school-age child may want to stay home from school to be with a surviving parent. Keep in mind that children and teens can also learn and grow following the death, find meaning from the experience and continue with healthy age appropriate development. For example, they may have more empathy towards others, especially in similar situations, feel confident in managing tough situations, learn useful coping skills, have a heightened sense of awareness of health, feel an increased responsibility to one’s family, rely on faith, be committed to education, or pursue particular passions, and appreciate what life has to offer.

Additional resource: https://www.kidshealth.org.nz/bereavement-reactions-children-young-people-age-group

Grieving children can experience a range of expected emotions, including sadness, worry, or anger. In addition, they may show a range of behaviors. They may have trouble sleeping, be withdrawn or irritable, or be unable to continue to enjoy activities, school, and being with friends. These can vary with their age and due to other factors associated with the death. Over time, the intensity and frequency of the difficult emotions and reactions decrease. Most children are able to talk about the person and share positive memories. However, some children may develop what is called Childhood Traumatic Grief. When this happens, traumatic stress reactions interfere with accomplishing what we consider typical helpful bereavement tasks (see answer 1). Traumatic reactions can happen after a sudden, traumatic death like a homicide or unexpected death such as a heart attack. However, children can also develop symptoms even if the cause was known, for example, cancer, if the child was scared, surprised or perhaps witnessed upsetting events. Their traumatic stress reactions can include (1) having intrusive images, thoughts or memories that come into their mind about the death, (2) exhibiting physical upset, for example, having headaches or stomach aches, (3) avoiding people, places, or things that remind them of the person or what happened, (4) having a negative mood, meaning feeling guilty or blaming themselves, not trusting others, or thinking they are unsafe and (5) having more arousal, worrying about others being hurt, and feeling on alert which can show up in their difficulty concentrating and sleeping but also in acting out behavior. The National Child Traumatic Stress Network (nctsn.org) has numerous books and resources for children, teens, parents and caregivers, as well as mental health, medical, and school professionals describing Childhood Traumatic Grief and how to support a child or teen who may be struggling. In 2022, the criteria for a diagnosis of Prolonged Grief Disorder (PGD) was added to the diagnostic and statistical manual used by mental health professionals. The guidelines for PGD identified specific characteristics for children, but caution the diagnosis should be made only after a minimum of 6 months. In contrast to Childhood Traumatic Grief, where the significant reactions are trauma related, PGD is focused on separation distress and longing.

If concerned about a grieving child or teen, it is important to seek out a mental health professional who can evaluate how the child is doing and any other contributing factors that prevent a child from doing their best. For example, a counsellor can carefully assess and tease out any overlap or difference among symptoms of trauma, depression and anxiety as well as developmental considerations for children and appropriate cultural responses to grief.

There are highly successful treatments such as Trauma Focused Cognitive Behavior Therapy, that is well researched and found to be effective in treating children with a traumatic stress reaction to a death. In therapy, children process the death in safe ways, learn skills to adapt to the loss and changes in their life, and remember the person. Parents/caregivers learn ways to support the child, and the family makes plans for the future and continues to thrive. Interventions for PGD with a cognitive behavior focus are also showing promise. It is extremely important for children to get the right help at the right time so the reactions do not take a long term toll of their physical and emotional health, relationships with family and friends, and performance at school and work. With the right information and care the outlook is hopeful for all grieving children.

The better the adults in a child’s life are doing, the better the child will be. Adults play a special role in helping children and teens with their grief. Not only is it key for them to provide support in the form of comfort, structure, and reassurance, but they are also role models. Children are continually learning from and paying attention to those around them for clues on how to act and behave. In general, when adults are finding ways to model their own grief, they should keep the age and personality style of the child in mind as well.

It is OK to be sad or cry, sending the message that it’s normal and acceptable. Adults can show the real ups and downs of grief, but it may be in a moderated way, saving the more intense emotions for alone time or when with trusted family and friends. Because children can be upset or scared when seeing adults have strong emotions, it is important to reassure children that big emotions are normal, will pass, and that you are still there to care for them. Acknowledging different feelings and showing by example how you take care of yourself and what you do to feel better, for instance, when sad, mad, worried, or lonely, is helpful. This can mean reminding a child you all eat healthily and go to the doctor. When having tough emotions, discuss things you do, creative and active ways to express them, and even options for coping together such as asking for a hug, watching a movie, going for a walk, or playing some music. Remember to also embrace positive emotions. In addition to the things that have changed, you can discuss what is the same. They may need to know they can still play and have fun. Certainly find ways that fit with you and your child to keep the person in your life by talking about feelings, sharing memories, and creating meaningful rituals. Staying connected to the person who died can be important, but so too are strengthening other important relationships and developing new ones.

Resource: https://www.newyorklife.com/assets/docs/pdfs/claims/Bereavement-bklet-English.pdf

Books are a wonderful way to help children understand and cope with their grief. They also give adults a way to talk about tough topics and provide an opportunity for conversations. Children and caregivers can also return to the books over time as grief evolves, questions arise, and memories are made. Below are some suggestions to find something that fits a specific child's age and situation.

· Brown, L. K., & Brown, M. (1998). When dinosaurs die: A guide to understanding death. Boston, MA: Little Brown Books for Young Readers. (ages 3-8) · Durant, A. (2004) Always and forever. Harcourt Children's Books. (Ages 3-7) · Harris, R. H. (2001). Goodbye, Mousie. New York: Margaret K. McElderry Books. (Ages 4-8) · Karst, P. (2000). The Invisible String. Camarillo, CA: DeVorss and Company. · Kerner, S. (2013) Always by my side. ‎ Star Bright Books. (Ages 5-8) · Levis, C. (2016) Ida, Always. ‎ Atheneum Books for Young Readers (Ages 4-8) · Mellonie, B., & Ingen, R. (1983). Lifetimes: A beautiful way to explain death to children. New York: Bantam. (Ages 3-8) · Mundy, W., & Alley, R. W. (1998). Sad isn't bad: A good-grief guidebook for kids dealing with loss. Elfhelp books. St. Meinrad, Indiana: One Caring Place, Abbey Press. (Ages 5-10) · Olivieri, L. (2007) Where are you? A child's book about loss. (Ages 4-8) · Parr, T. (2015) The Goodbye Book. Little, Brown Books for Young Readers (Ages 2-5) · Rowland, J. ( 2017) The memory box: A book about grief. ‎ Sparkhouse Family; Brdbk edition (Ages 2-7) · Thomas, P., & Harker, L. (2001). I miss you: A first look at death. Hauppauge, NY: Barron's Educational Series. (Ages 4-8) · Varley, S. (1984). Badger's parting gifts. New York: Lothrop, Lee & Shepard Books. (Ages 4-8) · National Center for Child Traumatic Stress (2015) Rosie remembers mommy: Forever in her heart (book and video in English and Spanish) (Ages 3-8) o https://www.nctsn.org/resources/rosie-remembers-mommy-forever-her-heart o https://www.nctsn.org/resources/rosie-remembers-mommy-forever-her-heart-sp o https://www.nctsn.org/resources/rosie-remembers-mommy-forever-her-heart-video o https://www.nctsn.org/resources/rosie-remembers-mommy-forever-her-heart-video-sp · Sesame Street Grief (English and Spanish) o Caring Card https://prod.drupal.aws.sesamestreet.org/sites/default/files/media_folders/Media%20Root/Grief_CaringCards.pdf o Something Small A Story About Remembering https://prod.drupal.aws.sesamestreet.org/sites/default/files/media_folders/Media%20Root/Grief_Storybook.pdf o When Families Grieve https://prod.drupal.aws.sesamestreet.org/sites/default/files/media_folders/Media%20Root/Grief_CaregiverGuide.pdf

· Viorst, J. (1987) The tenth good thing about Barney. Atheneum Books for Young Readers; (Ages 4-8)