Patient education: Helping a child cope with grief (The Basics)

Written by the doctors and editors at UpToDate

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What is grief? —

Grief is a normal, human response to loss. Grieving is a process that can affect a child's feelings and view of their life. It can also cause physical symptoms.

Some people only think of grief as it relates to the death of a family member, friend, or pet. Experiencing the death of a loved one is called "bereavement." But feelings of grief can also happen in children because of any type of loss. Examples include:

●Changes in relationships, like parents divorcing or a loved one moving out of the home

●Moving to a different school

●Moving or losing one's home

●Change in health or mobility

Society does not often acknowledge many of these losses. This can make grieving even more difficult.

How do children experience grief? —

Everyone grieves in a different way, and grief can change over time. There is no right or wrong way for a child to grieve.

A child's reaction to grief can also be different based on the type of loss. For example, the death of an older relative who was ill might cause a different type of grief than if someone died unexpectedly. The death of a parent or caregiver can be especially difficult for children. When a parent or caregiver dies, the entire family is affected.

Grief can affect all parts of a child's life. It can affect their:

●Emotions – Some children feel shock, pain, sadness, guilt or worry. Others might feel anxious, sad, or even relieved. Some might feel angry, and might direct it at anyone, like their family, their doctors, or even the person who died. All these are OK. These emotions can come and go for weeks to months. If the child's emotions are strong and continue for a year, treatment might be needed.

●Thoughts – It is normal to feel helpless or forgetful. Some children have trouble understanding things or feel confused. Others might doubt their faith or what they believe in.

●Behavior – Some children cry a lot, and others only a little or not at all. Crying can be a normal way to cope with strong feelings. Some children yell, wail, or are silent as a way to show their grief. Some feel very tired but have trouble sleeping. Some might not want to eat, and others might want to eat a lot. All these are normal reactions to grief.

●Relationships – Some children want to be around others, and others want to be alone. For shared grief, it can be hard when siblings, caregivers, or family members have different ways of grieving. For example, if a parent dies or is very ill, children of different ages often grieve differently.

How do children understand death? —

Death is a hard concept for many children to understand. They might not know what happens when something dies. The child's age, maturity level, and experiences all affect how they grieve and what they think about death and dying. So do the cultural and religious beliefs of the family. All these things guide how you should talk about death and grief with your child.

In general, a child's age determines how they understand death:

●Very young children (less than 3 years old) – They do not understand the concept of death at all. They get upset because the people who care for them are upset. Very young children might not be able to talk about how they feel. They might show their grief through crying, having temper tantrums, or being more clingy than usual. Try to keep their routine as normal as possible.

●Preschool-aged children (age 3 through 5) – They tend to see death as something temporary or reversible. Things like cartoons can support this belief. Children might go back to earlier behaviors like thumb sucking or wetting the bed. It is very important to be honest and clear with them, since they are very trusting. Using words like "passed away", "moved on," or "went to sleep" can confuse and upset them. Instead, say the person has died and the child cannot see them anymore. This can be very hard for you and your family. You might have to repeat yourself as the child tries to understand. Tell them how memories last forever. Give them extra love and attention.

●School-age children (age 6 through 12) – They start to understand death is permanent. They might think something they did or said could have changed or prevented the death. Reassure them nothing they did caused the death. They might react by having physical symptoms like headaches or stomach aches. They might act like they did when they were younger, or start to worry about their own health. Try to keep their routine as normal as possible.

●Teens – They start to understand death like adults do. But they might not be as good at expressing or handling their emotions. They might try to hide their feelings or withdraw from you and other adults. They might rely more on their friends for comfort. They might struggle to find meaning in the death, and might think about how it affects their own life and future. Some might turn to unhealthy ways of coping, like using alcohol or drugs. Give them opportunities to talk to you and others.

How can I explain death to my child? —

It can be hard for adults to talk about death. You might be dealing with your own emotions while trying to answer your child's questions and explain what happened.

To explain a death to your child, be honest and encourage questions. For example, you might say this to a younger child: "I have something very sad to tell you. Aunt Helen has died. This means her body has stopped moving. She doesn't move anymore because her muscles have stopped working. She doesn't breathe anymore because her lungs have stopped working. Her heart has stopped and will never start again. She doesn't feel anything and is not in any pain. I am sad because Aunt Helen died, and I will miss her. It is OK if you want to ask me any questions. I will try to answer them."

Children often ask questions about why or how a person died. It is usually best to be straightforward and honest. In some cases, like if the person died by suicide, what you tell the child might depend on their age and maturity level.

How can I help my child cope? —

Children cope in different ways. Grieving takes time and doesn't happen all at once. They usually begin to feel a bit better over time. This is normal.

Here are some tips to help them grieve and learn to cope in a healthy way:

●Help your child cope with their feelings – Talk with them about how they feel, and ask what they are thinking. Don't force a child to talk to you, but let them know you are interested and available.

•There is no right or wrong way for children to grieve. It is normal for them to experience many emotions like sadness, anger, or loneliness, sometimes at the same time. Children might feel guilty about times they weren't nice to the loved one.

•Try not to compare their reaction with others' or your own reaction. Each child processes and expresses grief differently. If a child or family member is handling grief differently from you, try to be patient and support each other.

•It is normal for children to ask questions. They might even play "funeral" with dolls or stuffed animals. It is a healthy way for them to make sense of the loss.

●Reassure your child – Remind them there are many people who love and care for them. Reassure them not every illness or accident ends in death.

•Clearly explain any changes in their routine, like where they will live or go to school if a parent or caregiver has died.

•Give them extra hugs. Let them sit on your lap or be close to you to feel safe.

•Cope with your own grief in healthy ways. It is OK to let children see you grieve, but also reassure them you are going to be fine and continue to care for them. It can help to share stories about a loved one you had and lost when you were younger. Tell them it was hard to say goodbye, but you were able to heal and move on.

•It can help to talk to a therapist or grief counselor. They can help you cope with your and your child's grief. There are also support groups for children who have had a similar type of loss.

●Help your child cope with healthy activities – Some children will try to do too many activities to distract themselves from their grief or avoid it. But some activities can help them cope with strong emotions.

•Read stories about grief or watch a sad movie together. Let them hit a punching bag or squeeze a stress ball. These things can let them express their emotions safely.

•Do things they enjoy with them. Tell them it is still OK to laugh and have fun. This does not mean they have forgotten the loved one or are finished grieving.

●Help your child remember the loved one – Tell them it is OK to think about the loved one sometimes. Talk to them about how they would like to honor the loved one.

•Talk about what will happen at the funeral and the cemetery so they are prepared. Decide together if they will have a role in the ceremony. You might want to have another family member focus on caring for your child during this time so you can cope with your own feelings of grief.

•Consider letting the child keep something that belonged to the loved one.

•Tell stories or draw pictures together. Light a candle, and look at photos or videos of the loved one. It can be comforting to talk about a loved one who died.

•Help them create a memorial. Make a garden, or plant a tree, rose bush, or flowers.

•Plan for how to help them cope with holidays, birthdays, anniversaries, or other times that might trigger strong feelings.

Get help right away if your child is thinking of hurting or killing themselves! —

Sometimes, children who are grieving have thoughts of hurting themselves. Or they might feel they want to die to be with their loved one. If you ever think like a child might hurt themselves or someone else, help is available:

●In the US, contact the 988 Suicide & Crisis Lifeline:

•To speak to someone, call or text 988.

•To talk to someone online, go to chat.988lifeline.org.

●Call their doctor or nurse, and tell them it is urgent.

●Call for an ambulance (in the US and Canada, call 9-1-1).

●Go to the emergency department at the nearest hospital.

When should I call the doctor? —

Call for advice if:

●Your child has trouble doing their regular activities for a long time.

●Your child blames themself for the death.

●Your child's grief seems to be getting worse or not getting better over time.

●You child seems withdrawn and loses interest in daily activities.

●Your child has big changes in their behavior, such as substance misuse, acting out, or acting younger for a long time.

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Patient education: Helping a child cope with grief (The Basics)