Q&A: How to support grieving children
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Key takeaways:
- Many people falsely assume that young children are unable to grieve.
- The pandemic affected people’s views on discussing grief and bereavement.
In an updated clinical report, the AAP offered guidance for pediatricians on how to address grief in young patients.
The report, updated for the first time since 2016, contains practical suggestions to help bereaved children better understand death and its implications, anticipate and address grief triggers, and advice on how to support a child’s participation in a funeral or memorial service.
According to the report, the guidance is meant to put pediatricians and providers “in a better position to advise caregivers and to offer consultation to and collaborate with professionals in schools, early education and child care facilities, and other child congregate care sites.”
To learn more, we spoke with David J. Schonfeld, MD, FAAP, director of the National Center for School Crisis and Bereavement at Children’s Hospital Los Angeles, a member of the AAP’s Council on Children and Disasters, which cowrote the report with the AAP’s Committee on Psychosocial Aspects of Child and Family Health.
Healio: What has changed in the years since the 2016 clinical report?
Schonfeld: There are a couple of things that have changed over that time period.
Bereavement has been something that children have always had to deal with — even before the pandemic, about 90% reported that they experienced the death of a close relative or friend at some point during their childhood. At a basic level, the fundamental experience of bereavement hasn’t changed.
But the pandemic was a unique context. Children experienced deaths of those they knew at even higher levels and often had to deal with multiple losses, or what we call cumulative losses, during a short period of time, and often without much support from others because of the social isolation. They also had to deal with a lot of grief beyond bereavement. They had to grieve lost opportunities — attending school, companionship of friends, social interaction, graduations and other special occasions, a sense of safety, etc.
As a result, the experience of grief for children in general, and bereavement specifically, was impossible to ignore. I have done this work for over 35 years, and although people always found information on how to support grieving children interesting when I brought it up, now they were actively seeking this information.
We did focus groups after our trainings of educators in New York City during the pandemic, and I was surprised by not only how much they wanted and valued this training, but [that some] didn’t think one training was enough. They said that they thought this training should be given every year. Whereas in the past, it was harder to get the attention of people to focus on the importance of this topic — which many find difficult to discuss — the demand for this training became much greater.
We also saw that, during the pandemic, even professional helpers were grieving personal losses. I was doing training on bereavement several times a day, even when I was coping with close personal losses myself.
The pandemic increased awareness and demand for training, but it also presented in a more complex context in which to address this challenge. The AAP also committed during this time to a conscious effort to more fully address diversity, equity and inclusion and wanted to apply this to the topic of children’s bereavement in this current update. Children of color, for example, were more likely to experience deaths of caregivers and other close family members because of the disproportionate rates of deaths within communities of color and those living in poverty. These children also had to deal with the intersectionality of grief with the other major stressors associated with discrimination and systemic racism. The communities where they lived also tended to have far less resources and support.
So, although the fundamental experience of bereavement in children is quite similar, it took on a different nature. In planning the update to the clinical report, we wanted to consider certain recent events — such as the pandemic — that posed some new challenges, and also make sure that we gave more careful consideration to the heightened challenges of grief among children who are in marginalized groups that have dealt with discrimination.
Healio: Are there any common misconceptions about how children grieve?
Schonfeld: One misconception is that children don't grieve until they reach a particular age, and what people think that age is varies. In reality, even infants who don’t understand what death means still experience and react to the distress expressed by caregivers and other family members after someone has died.
During the second half of the first year of life, infants start to understand object permanence — they begin to realize that even when people they care about are out of sight, they continue to exist. Once they develop object permanence, they can experience permanent loss — and they begin to be concerned about it.
In the report, we include the example of peek-a-boo, which is a game that children of the same developmental age play in cultures around the world. It’s one of the first games about death. Most people are surprised to learn that the literal translation of peek-a-boo in Old English is “alive-or-dead.” Many people, therefore, falsely assume that infants, toddlers or very young children aren’t able to grieve, or simply don't grieve. Part of that is because children learn from a very young age that this topic makes adults uncomfortable. If someone dies in their family and they ask relatives about it, their questions are often poignant and cause adults to lie. Children frequently conclude that the questions or their efforts to talk about the complicated feelings of grief are naughty and they try not to bring it up. This can give adults the false impression that children aren’t grieving.
Healio: What are the specific recommendations for pediatricians?
Schonfeld: The report recommends that pediatricians become more aware of grief, even in young children, and develop the skills to help children understand and cope with loss. They can then provide important guidance to parents and other caregivers of grieving children about what they can do to better support the adaptation of children who are grieving.
Healio: When should a pediatrician refer a child in this situation for counseling?
Schonfeld: Grief is viewed in pediatrics and the mental health field — as well as in society in general — as a normative life experience. Everyone experiences bereavement at some point, including the vast majority of children. Grief reactions are, therefore, not viewed as “symptoms” because they aren’t part of a disorder or illness.
Most grieving children therefore don't receive treatment or counseling — but they should receive support. That type of support for the vast majority of children who are grieving need not be provided by a mental health or medical professional. Most children's bereavement programs, groups and camps aren’t staffed by mental health professionals but rather by faith-based professionals, or usually lay people who have received modest training on how to support grieving children effectively. I do see more children's bereavement groups and programs include mental health providers these days, but most of the staff are not mental health professionals, and some bereavement programs have no mental health professionals.
We do recommend referring children to professionals for counseling or therapy when their grief is “complicated,” such as when it is prolonged, more intense and/or associated with serious emotional issues such as depression or suicidal ideation, or associated with behaviors that may be dangerous, such as alcohol or other substance [use], or risky behaviors.
We should offer bereavement support to all children who have experienced the death of a close relative or friend, whether that's through groups or camps or involves talking individually to a school counselor. We shouldn’t wait until their grief passes a certain threshold or they begin to fail in school or demonstrate symptoms of a mental illness. Coping with the death of someone close to us is difficult; we should offer support to all grieving children.
In the past, there was a tendency to often ignore the grief of children. It’s a difficult topic that many adults try to avoid. This leaves children to grieve in isolation. It takes them longer to cope as a result. I think the pandemic [showed] we can’t ignore this. Hopefully, one outcome of this tragedy is that we finally have reached the point where this is no longer hidden and where people start to feel more comfortable talking about it — although it will likely always be somewhat uncomfortable for people.
What I have seen after responding to crisis and loss over the years is that once people see the distress that children feel in these situations, it’s something that is difficult to unsee. Hopefully, we have turned the corner on understanding and addressing childhood bereavement because even though the pandemic has ended, death and loss in some form will always be a part of life.
References:
Schonfeld DJ, et al. Pediatrics. 2024;doi:10.1542/peds.2024-067212.
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