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Keep in mind that children do not move abruptly from 1 stage of development to the next.


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And features from each stage may overlap. May react to the absence of a parent or caregiver with increased crying, decreased responsiveness, and changes in eating or sleeping. May see death as something like sleeping. In other words, the person is dead but only in a limited way and may continue to breathe or eat after death.


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Often feel guilty and believe that they are responsible for the death of a loved one, perhaps because they were "bad" or wished the person would "go away. Cannot put their feelings into words and instead react to loss through behaviors such as irritability, aggression, physical symptoms, difficulty sleeping, or regression such as bed-wetting or thumb-sucking. May experience a range of emotions including guilt, anger, shame, anxiety, sadness, and worry about their own death. Struggle to talk about their feelings. Their feelings may come out through behaviors such as school avoidance, poor performance in school, aggression, physical symptoms, withdrawal from friends, and regression.

May worry about who will take care of them, and will likely experience feelings of insecurity, clinginess, and abandonment. Have an adult understanding of the concept of death but do not have the experiences, coping skills, or behavior of an adult. May act out in anger at family members or show impulsive or reckless behaviors, such as substance use, fighting in school, and sexual promiscuity. May experience a wide range of emotions but not know how to handle them or not feel comfortable talking about them.

May not be receptive to support from adult family members because of their need to be independent and separate from parents. Explain death in simple, direct, honest terms geared to your child's developmental level.

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Children cannot reflect on their thoughts and emotions like adults. So they will need to have many short conversations. Adults may need to repeat the same information many times. Children may ask the same questions often as they try to make sense of difficult information.

Explain death using real words such as "died" rather than confusing phrases such as "gone to sleep. Encourage your child to ask questions, and try to answer them honestly and directly. If you do not know the answer to a question, help find the answer. Make sure your child understands that he or she is not to blame for the death and that the person who died is not coming back. Provide lots of affection and reassure your child often that he or she will continue to be loved and cared for. Encourage your child to talk about his or her emotions.

Bereavement: Reactions, Consequences, and Care.

Suggest other ways to express feelings, such as writing in a journal or drawing a picture. Without overwhelming your child, share your grief with him or her.

Expressing your emotions can encourage your son or daughter to share his or her own emotions. Help your child understand that normal grief involves a range of emotions, including anger, guilt, and frustration. Explain that his or her emotions and reactions may be very different from those of adults. Reassure your child that it is normal for the pain of grief to come and go over time. Explain that they cannot always predict when they will feel sad.

According to Nagy's stage 1 roughly ages , death is seen as reversible; the dead are simply considered "less alive," in a state analogous to sleep. Young children functioning at what Piaget termed the "preoperational" level of development will not generally recognize the irreversibility of death. In the third stage after age 10 , the causes of death can be understood, and death is perceived as final, inevitable, and associated with the cessation of bodily activities. As is true in all child development, there is considerable age variation in attainment of the different stages and children may regress when emotionally threatened.

Prior to about six months of age, infants fail to respond to separation from their mothers because they have not yet developed the capacity for memory of a specific personal relationship.

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Resources for adults supporting bereaved children and young people

This reaction suggests that an infant is developmentally capable of retaining memory traces of his mother and is capable of responding to her absence with displeasure and depression. Observational studies of children between about four years of age and adolescence have led psychiatrists to conflicting conclusions about the nature of children's grieving and about their ability to achieve a healthy outcome.

Some psychoanalysts 3 , 42 , 75 , , maintain that it is not until adolescence that children have the capacity to tolerate the strong painful affects necessary for completing the separation process and that children are more likely to use immature defense mechanisms, such as denial, that interfere with adequate resolution of loss.

Thus these observers view children's reactions to loss as qualitatively different from adult reactions. Others believe that after object constancy has been achieved at three to four years of age , bereavement need not necessarily lead to enduring psychopathology. Increasingly, it is being recognized 27 , 55 , 81 that if the child has a consistent adult who reliably satisfies reality needs and encourages the expression of feelings about the loss, healthy adjustment can occur.

Furthermore, the biologic unfolding inherent in development naturally pushes children toward increasing cognitive and emotional maturity. This "developmental push" is seen as an asset that contributes to children's potential resiliency under favorable circumstances. Some psychiatrists, most notably Bowlby, 24 emphasize the similarities between adults' and children's responses to loss and see an evolutionary basis for them.

In Bowlby's view, the argument about children's capacity for "mourning" is in large part terminological, with many psychoanalysts restricting the use of "mourning" to psychological processes with a single outcome—detachment—and others using it more broadly ''to denote a fairly wide array of psychological processes set in train by the loss of a loved person irrespective of outcome. Kliman suggested at one of the committee's site visits that perhaps too much concern has focused on this debate. In his opinion it would be more fruitful to have a detailed understanding of the bereavement process in children so that those who interact with children can be most responsive and helpful.

Most of the literature on bereavement in childhood is based on observations of disturbed children who are in psychotherapeutic or psychoanalytic treatment. On the other hand, random samples of bereaved children that provide more methodologically reliable data do not offer the same depth of information.

In addition, relatively few use control groups, making it impossible to know what the base rates of particular behaviors or symptoms might be in the general population. Where controls are used, it is often unclear whether they are matched for age and sex. Most of the data on very early below the age of five childhood loss are not specific to bereavement but are based on observations of institutionalized children e.

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It is not clear if the children's responses in these studies were based on parental loss itself, on the multiple other losses associated with removal from the home environment, or the unfamiliar and sometimes chaotic circumstances associated with institutional placement. Because these children were not followed over a very long period of time, neither is it known whether pathologic or disturbing reactions endured.

Studies of the long-term effects of bereavement during childhood are abundant, but they are highly controversial because they almost always rely on retrospective data see Gregory 63 for a discussion. In addition these studies often fail to consider the impact of intervening life events, rely too heavily on data based on patients' memories, and use inappropriate control groups.

A handful of prospective studies describe intermediate effects, but many of these have methodologic flaws, such as a failure to use nonbereaved control groups, 78 , a lack of direct assessment of bereaved children, and a failure to follow children over a sufficiently long pe riod of time. Different methods have been used to study outcomes of childhood bereavement and, partly because of the variation in approach, studies have yielded different results. Few studies provide precise definitions of key terms, such as "depression, "exaggerated responses, " "pathologic grief, " "anger, '' and "sadness," so it is difficult to know whether all authors are referring to the same specific reactions.

Studies on childhood loss tend to rely exclusively on interview data or material in case files; standardized instruments that permit greater generalization across studies have rarely been used in the assessment of children.

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In fact, such instruments have only begun to be developed in the past few years. It should be noted that, because of the way this chapter is organized, a number of studies are cited several times, perhaps giving the impression that there are more empirical data than is really the case. The death of a parent during childhood has been linked with a wide range of serious and enduring health consequences ranging from schizophrenia to major depression and suicide see Table 1 for a summary of key findings from each of the major studies.

The particular symptoms and syndromes associated with childhood bereavement are generally considered in terms of the immediate reactions that occur in the weeks and months following the death, the intermediate reactions that can appear later in childhood or adolescence, and the long-range or "sleeper" effects that may appear in adulthood either as enduring consequences or delayed reactions to the loss. Although these long-range effects are of most concern, the research evidence in this area is probably the weakest. Children, like adults, experience a range of emotional and behavioral reactions immediately following parental or sibling death.

Studies of both patient and nonpatient samples report that children respond to loss with similar symptoms.

People who interact with recently bereaved children find them sad, angry, and fearful; their behavior includes appetite and sleep disturbances, withdrawal, concentration difficulties, dependency, regression, restlessness, and learning difficulties. They also note that initial symp tom patterns depend largely on the age at which the child is bereaved. For example, children under age five are likely to respond with eating, sleeping, and bowel and bladder disturbances; those under age two may show loss of speech or diffuse distress.

School-age children may become phobic or hypochondriacal, withdrawn, or excessively care-giving. Displays of aggression may be observed in place of sadness, especially in boys who have difficulty in expressing longing.

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Adolescents may respond more like adults, but they may also be reluctant about expressing their emotions because of fear that they will appear different or abnormal. A limited number of investigators 45 , 46 , 81 , , , followed cohorts of parentally bereaved children for one to six years after death. Others e. Medical Consequences.