Grief is described as the inward process following the death while mourning takes on characteristics of outward expressions of grief or the sharing of ones story. Grief is an adaptive process that has several components. Harrington(1982) defines grief “not as a state or set of symptoms, but a succession of clinical pictures which blend into and replace each other”. The four dimensions of the mourning process outlined by Bowlby and Parkes (1970) are shock and numbness, yearning and searching, disorientation and disorganization, and resolution and reorganization. The four dimensions do not follow a set order and a person may experience feelings from several stages at one time. (Bowlby, Parkes 1970)
Children do not grieve as adults. Their grief vastly differs from the adults. As their understanding of death and perceptions of the world change, they often grieve in spurts and re-grieve at new developmental stages. Childhood grief is often expressed as behavioral changes or emotional expression. A child’s successful outcome after suffering a loss depend on the two most important predictive factors which are the availability of one significant adult and the provision of a safe physical and emotional environment. (Alan Wolfelt, 1983) A great deal of variation is there among children and a large number of factors influencing development. In addition to normal variation, children under stress as when they experience a loss may regress to an earlier level of development. They adopt a variety of coping techniques that are developmentally appropriate but are, nevertheless, distressing to adults that lead to problems in relationships with others.
A child goes through four developmental stages years between birth and age 21. The first one being Sensorimotor consisting of very young child roughly from birth to age 2 Infant age from 0-2 years old. Second development stage is Preoperational consists of Early Childhood preschool children approximately 2 through 6. Next is Concrete Operational stage is Middle Childhood where the schoolchildren are of ages 6-12 years. The last development stage is the Formal Operational consisting of Adolescent of ages 12-21 year old. Each stage is marked by a period of continuous change in cognition, feelings and physical development. Almost every area of life through each developmental stage was controlled by circumstances outside of the influence of the child. (Alan Wolfelt, 1983)
Sensorimotor: Infant 0-2 years
Infants do not appear to grieve in the same sense as adults and older children do. Scholars view infants as experiencing a disruption of their environment rather than genuine grief. Others propose that infants experience grief and have an emotional response that is consistent with their level of cognitive development. Infants are highly organized and engage in their level of meaning making in a social context, that children at this age have no cognitive understanding of death. However, grief reactions are possible and separation anxiety is a concern. (Himelstein BP et al, 2004) As infants have difficulty, identifying and dealing with their loss behavioral and developmental regression occur; they react in concert with the distress experienced by their caregiver. To avoid grieving and separation from mother or caregiver routines should be maintained.
Preoperational: Preschool 2-6 years
Death is temporary and reversible as perceived by preschool age children. They interpret their world in a concrete and literal manner and ask questions reflecting this perspective. Most of them believe that death can be caused by thoughts and provide magical explanations, often blaming themselves for the death. Simple and straightforward explanations must be provided, avoiding euphemisms, correcting misperceptions, and reminding them that the loved one will not return are important strategies.
Concrete Operational: School Age 6-8 years
Death is often personalized or personified by young school going children. They understand that death is final and irreversible but do not believe that it is universal or could happen to them. Expression of anger towards the deceased or towards those perceived to have been unable to save the deceased can occur. Anxiety, depressive symptoms, and somatic complaints may be present. (Trozzi M, Dixon S. 2000) The child often has fears about death and concerns about their other loved ones’ safety. In addition to giving clear realistic information, the child should be included in funeral ceremonies. The school must be notified to help teachers understand the child’s reaction and additional adult support provided.
Pre-adolescent 8-12 years Pre-adolescent children have an adult understanding of death; they understand the biological aspects of death as well as cause and effect relationships. Death is final, irreversible, and universal, many intellectualize death, as they have not yet learned to identify and deal with feelings. They develop a morbid curiosity and are often interested in the physical details of the dying process and they are interested in religious and cultural traditions surrounding death (Himebauch A, Arnold R and May C. 2005). To help children identify with their emotions is often facilitated, by talking about your own emotions surrounding death and to offer opportunities for the child to discuss death. Hogan and Balk (1990) found that even though adolescents usually turn to mothers for understanding after a loss, fathers actually were found to have a more accurate picture of the grief experience of the adolescent. The child should be allowed to participate, as much as they are comfortable, being with the dying patient and participating in activities surrounding the death.
Formal Operational: Adolescent 12-18 years
Adolescent’s grief is quite similar to adult grief. It is also defined as depression, feeling of emptiness, bouts of crying, severe headaches, insomnia, digestive upsets and exhaustion. In many children, grief is evident in confusion, crying spells, and depression, loneliness; disturbances in patterns of sleep, eating disorders, and stress. Adolescents also have an adult understanding of death. They have the ability to think abstractly. Moreover, are often curious of the existential implications of death. These adolescents reject adult rituals, support, and feel that no one understands them. In order to challenge their own mortality they engage in high-risk activities. (Koocher, GP. 2004) These children have strong emotional reactions and have difficulty identifying and expressing feelings.
Adolescents hide their grief even though it is enduring. It concerns them to be seen as odd by valued peers. They also hide their grief from adults in order to maintain a sense of separateness from them. The grief is both intermittent and continuous and losses are slowly resolved. The grief is extended over a longer period as they are less likely to resolve it (Pynoos, R 1992).
Depending on the type of loss and the developmental stage of the child, their experience of grief varies. Moving to a new town may precipitate a grief response that is mild and transient, while grief from loss of a parent threatens the foundation of the child’s world. Young children express grief in vastly different ways from teens and adults. A child’s grief is complicated because it is linear, circular, and developmental. There are three stages in Child’s grief known as Disorganization, Transition and Reorganization.
The first stage is Disorganization: It is the initial expressions of grief in children. In younger children, it range from regression, tempers tantrums, and exaggerated fears. In older children, it ranges to physical symptoms, lack of concentration, and mood swings. The disorganization of early grief is a true crisis for children, but parents and loved ones should help the child through this stage. Next comes the Transition phase where there are feelings of hopelessness and helplessness. Despair follows the stress and chaotic behaviors of the disorganization stage and many children exhibit true depression. Withdrawal, aggression, and giving up in school are the common symptoms. According to Moses, “the feelings experienced during the grief process serve a specific function and can be viewed as protective mechanisms for the person experiencing the loss” (Moses, KL. 1983) Denial, for instance, is a defense mechanism people use to block the conscious recognition of specific information. Denial allows a patient or parents to “take in” what they are capable of handling mentally, emotionally and physically. Lubinsky (1994) suggests that denial is often confused with disbelief, deferral and dismissal.
The last stage is Reorganization when painful feelings are expressed their emotional energy wanes, and detachment becomes possible. Children have more energy and motivation for moving forward to a positive resolution of their grief during this stage. Research conducted by Davidson (1979) demonstrated that the intensity of feelings within each stage rises and falls throughout the first two years following the loss of a loved one.
Though children’s grief follows this progression, it is complicated by the circular nature of grief. If one has experienced grief in life, one knows this to be true. Just when one has moved forward in resolution of grief, reminders of the loss floods with emotions that bring right back the feelings of despair and great sorrow. Adults recognize and understand what is happening with their emotions; children often cannot. Parents must recognize the circular nature of grieving to help their child through difficult times during their development. (Cohen, J.A et al 2002).
A loss and related grief are not contained in one developmental stage. It becomes part of whom a person is and affects throughout life. The loss addressed repeatedly as one moves through new developmental stages, transitions from one status to another, and experiences new situations. With each re-working, new resources will be used and a new appreciation for the loss will be developed. The experience of a loss can be positive as well as negative. In a study done by Martinson and Campos (1991), for adolescents whose sibling had died of cancer seven to nine years before, good communication in the family, the ability to share the death experience with others, expression of pleasure in the sibling’s company, and reliance on family for emotional support were related to a more positive long-term outlook. A more negative outlook was related to withdrawal from family interaction, inability to use the family as a source of support, and difficulty in discussing their experience with others.
For small children play is the “work of children” and they use it the same way that adults use work to distract themselves from their thoughts and feelings. They use it to work through loss issues. Death themes in games they play distress adults, however, and they need to be aware of the importance of children being able to use play for this purpose.
The effects of a loss is experienced throughout children and adolescents lives. Attempting to avoid the reality of their grief will not make it “go away”. Rather, it is simply sealed to be exposed again, possibly with greater intensity, since it has not been dealt with at an earlier time
Conclusion
It is evident that the grief of children and adolescents is far more complex than many adults assume. The simple fact is that children and adolescents go through a grief experience that is limited by their developmental level. Just because children and adolescents are not confiding in adults it does not mean that, their loss is integrated and that they have “moved on”. Adults, in general, and parents, in particular, need to recognize their children to be innocent and protect them from any harm. The final consideration in helping children live through grief is the developmental stage of the child. It is important to note that a grieving child’s developmental stage may lag behind his chronological age. Regression is expected and developmental accomplishments take longer to achieve. Young people regardless of their age, need an adult they can trust, to help them understand what is going on and to help them feel secure.
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