Nicolas was just under 3 years old when he attended his grandfather’s funeral. He wandered through the sea of adults, holding tight to his mommy and daddy’s hands as he made his way to the front of the line where his grandfather lay peacefully in the casket. His grandmother picked him up as he tried to climb into the casket. “Sleeping?” he asked his grandmother. “No, sweetheart. Your grandfather died.” Nicolas paused looking at the man in the box and back at his grandmother, “Sleeping?” he tried again. “No, he has died. He is not sleeping”, the grandmother replied softly. Nicolas looked around and attempted to contort his face — mimicking the adults around him. “They are sad, honey. When someone dies, we can feel sad,” his grandmother attempted to explain. Nicolas just watched, trying to imitate the adults around him as the man in the box continued to sleep.
According to William Worden, psychologist and grief expert, all children grieve regardless of age and stage of development. However, each stage provides a different understanding of death and loss. Grief can be experienced in a variety of ways. A child may experience a physical manifestation such as shock, or somatic ailments. They may feel anxious, angry, depressed or withdrawn. The children may act out behaviorally, resulting in biting or hitting. Additionally, there are critical periods where adverse experiences impact the neurological development of children in more critical ways. Having an understanding of how developmental stages affect the manifestation of grief can help counselors provide more effective support for children who have experienced a loss.
Infants and preschoolers: Infants and preschool age children experience life through their senses. Object permanence doesn’t become established until approximately 28 months. Therefore, children at this age may experience grief as the annihilation of existence: now you see me, now you don’t. Challenges resulting from loss at this age include a desire to connect to others but not knowing how, which may cause either clingy or standoffish behavior. A child may also exhibit a decrease in impulse control and tolerance, an increase in uninhibited behavior and poor emotional regulation, and possibly difficulty with toilet training. This is a critical period, neurologically. Neurons that fire together, wire together. Therefore, losses at this age have a higher chance of impacting children in significant ways.
School-age children: As children continue in their development, they are able to recognize attachment relationships, and they may experience loss as abandonment. School-age children may become preoccupied with death, which may become demonized during this stage, and children may experience anxiety related to the idea of mutilation. For example, children in this age group may talk of “blood and guts” and the Grim Reaper when referring to death. Children during this age are capable of conceptualizing loss as permanent and experience magical thinking. Grief may manifest as hyperactivity, emotional eating and/or somatic complaints. Children may withdraw or become argumentative and demanding. They may have difficulty concentrating and demonstrate a decrease in academic performance. Additionally, they may identify with the deceased by exhibiting similar behavior or experiencing symptoms of a loved one’s terminal illness. For example, Tony, an 8-year-old client came to me experiencing pain in his chest. A full pediatric work-up did not find a physiological etiology to his discomfort. However, in his intake, Tony stated that his grandfather had just died. When I asked his parents about Tony’s grandfather’s death, they indicated that he had died of lung cancer. Tony’s chest pain appeared to be a somatic manifestation connected to his grandfather, and after a few months in play therapy, Tony was able to work through his grief in a way that allowed him to find other ways to remember his grandfather.
Adolescents: Adolescents are capable of abstract thinking and struggle with the concepts of being versus non-being. While teens may feel immortal, they have increased awareness of the permanence of death. They may begin to think about death in terms of their own mortality. Teens may have experienced a variety of losses by now, and are better able to differentiate between types. The death of a distant elderly relative may feel different than the loss of a close friend.
Grief may manifest in a variety of ways including survivor’s guilt, a reduced sense of spontaneity, self-medicating (food, drugs, sex, etc.), social isolation and cyber mourning. Thanatechnology, or the use of media and technology to mourn, may be a way to seek comfort and connection through mourning sites, grief blogs and music playlists. However, it may also be a venue to glamorize loss in an unhealthy manner.
For example, I was working with a 16-year old girl who was devastated by the sudden death of her classmate by drug overdose. In addition to experiencing survivor’s guilt, she began engaging in high-risk behavior such as getting intoxicated at parties and offering sexual favors. This was a complicated situation as the client was not only grieving her classmate but also struggling with her own identity and self-worth. “Why should I live and she die?” We used an online memorial site to create a digital scrapbook of her friend’s favorite music, poems and pictures of special places they had gone together. I watched my client (and, with her permission, the memorial they had created) carefully. I started to get concerned as it remained a dark space for several months with little construction of hopeful meaning in sight. One day while the client was lamenting this loss, I asked, “Where would you have liked to go with your friend?” This led to a discussion about how the client and her friend had talked about hiking the Appalachian Trail when they graduated from high school. I grinned and said, “What a lovely tribute to your friendship to keep that promise.” By the next session, she had begun adding pictures and maps of the Appalachian Trail, marking the route she planned to take in a post-graduation trip to honor her friend.
Grief Work
It’s important to acknowledge that the deaths of family members or friends are not the only losses which can cause grief in children. For example, the death of a beloved pet, the divorce or separation of parents or a move to another school are all events that can evoke a significant 
sense of loss. It is vital to honor and understand these losses and ensure that children are allowed to express the accompanying grief.
Recognizing the varied symptoms of grief in children is essential as it may be masked in a variety of behaviors resulting in misdiagnosis and treatment. Even the most well-intentioned clinician or educator may misread and pathologize a child’s lack of concentration, fidgeting and restless behavior. This was the case for 5-year-old Andrew whose grandmother died suddenly from a heart attack. Andrew was very close to his grandmother, and even though his parents provided him with age-appropriate information around her death, Andrew began eliciting restless and inattentive behavior at school. Even though [his teacher was] aware of the death, notes were still sent home daily indicating that Andrew was disruptive in class. On the last day of the week, and the day before Andrew’s grandmother’s memorial service, the teacher’s note read, “Andrew is exhibiting signs of ADHD.” Andrew had not previously experienced difficulty in class. This is an example of a misdiagnosis. Andrew did not need medication or treatment for attention deficit hyperactive disorder (ADHD), but support during his grieving process.
After all, the goal of grief work, according to Worden, is to emotionally relocate the deceased loved one in a way that allows the child to move forward. In this way, children discover ways to remember the loved one in a healthy way. This involves helping children create connection to self, to others and to the sacred.
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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.
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