Age, sex and where they are developmentally are among the factors that determine how a child or adolescent reacts to loss, tragedy and death.

Early Childhood: Birth to 2+ years

Preschoolers and Kindergartners (3 - 5 years)

Grade School (5 - 9 years)

Pre-adolescent/School Age (9 - 11 years)

Middle School: Early to Mid-adolescence (11 to 15 years)

High School - Mid-to-Older Adolescent & Young Adult (15 - 19 years)

Children of this age are unable to describe how they are feeling. They may not know what is going on but they are likely to pick up on the parent's anxiety or apprehension. Children of this age involved in a trauma can retain memories of particular sights, sounds, or smells. When they are older, these memories may emerge in their play.

Infants:
Infants are unable to recognize death, but can experience feelings of loss and separation as part of developing an awareness of death. Children separated from their mother may become sluggish, quiet, unresponsive to a smile or a talking, undergo physical changes (for example, weight loss), be less active, and sleep less. Infants may also become more irritable, cry more often and need to be held and cuddled.

Toddlers:
Toddlers often confuse death with sleep. Children as young as 3 may experience anxiety, stop talking and appear to feel overall distress.

Ways of helping:

• Try and stay calm around babies and toddlers. They will calm down with caring.
• Maintain the child's normal routine as much as possible. This is reassuring for babies and young children.
• Shield babies and toddlers from media reports as much as possible.
• Activities: Hold and cuddle as needed.

Children of this age are not always able to distinguish between fantasy and reality. The child's concept of death may involve magical thinking. For example, the child may think that his or her thoughts can cause another person to become sick or die. Generally, they do not understand the concept of a permanent loss, or believe that death is final. They believe that consequences are reversible and see death as a temporary separation from loved ones, that death is a kind of sleep. Children may think that the person is still living and ask questions about the deceased. Adults should be aware that preschoolers and kindergartners can be more aware of what has happened. They may hear adults talking about the death, loss or tragedy or hear or see media reports.

This age group is most concerned about their own safety and the safety of their parents, relatives and friends. When the safety of their world is threatened, they feel insecure and fearful. Faced with an overwhelming event—death, loss or tragedy, very young children may feel helpless, powerless, and unable to protect themselves. Parents should acknowledge to their children that something very scary has happened, but that they will be safe. Abandonment is a major childhood fear, so this group needs frequent reassurance they will be cared for and will not be left behind. Grieving children under the age of 5 may have trouble eating, difficulty sleeping, and problems controlling bladder and bowel functions.

Ways of Helping:

• Use metaphors to explain death e.g. seashell, cocoon becoming a butterfly, so that they can begin to understand and accept death as a part of life.
• Avoid allowing preschoolers and kindergartners watching news reports of frightening events.
• Let them know that parents, family and other significant adults will make sure they are safe.
• Provide lots of comfort—hugs, physical and verbal reassurances.
• Reassure them that frequently they will be cared for and not be left behind.
• Activities: play acting, physical contact, puppets, art, stories, large muscle movement (throwing balls, etc.).

Grade school aged children are beginning to understand death as being final. Death may be thought of as a person or spirit separate from the person who was alive, such as a skeleton, ghost, angel of death, or "bogey man." Younger children in this group may see death as being accidental. Older children associate death with old age. They may have difficulty understanding that someday they will die. It is common for children of this age to be very curious about death, asking many questions. Loss may be seen as a punishment for bad behavior. Children may feel abandoned especially if their parents are grieving and unable to emotionally support the child. In the case of the death of a parent, the child may feel doubly abandoned, by the deceased parent and the grieving parent. Children of this age group need frequent reassurance they will be cared for and will not be left behind.

Normal Reactions:

• Blames self for loss.
• Fear of school
• Easily distracted, forgetful.
• Reduced desire to do anything.
• Exaggerated fears e.g. dark, health, safety
• Developing antisocial or agressive behaviors
• Withdrawing from others
• Developing symptoms of imaginary illness, becoming overly concered about their own health.
• Becoming attached and clingy.
• Regressive behaviors
• Boys in particular may become more aggressive and destructive, acting out in school, instead of showing their feelings.

Ways of Helping:

• Encourage exploring nature to understand the life cycle, watching plants grow and die, seasons change.
• Use metaphors to explain death e.g. seashell, cocoon becoming a butterfly, so that they can begin to understand and accept death as a part of life.
• Let them know that parents, family and other significant adults will make sure they are safe.
• Be prepared to provide answers for their questions.
• Provide lots of comfort—hugs, physical and verbal reassurances.
• Reassure them that frequently they will be cared for and not be left behind.
• Activities:
• Younger (5 - 7): physical contact, puppets, art, stories, large muscle movement (throwing balls, etc.).
• Older (7 - 9): play acting, puppets, drawing and painting, sharing their experiences in groups, reading, creative writing or discussion.

By the time a child is 9 years old, death is known to be unavoidable and can be seen as a punishment. Children at this age are able to understand the permanence of loss from a trauma. Since their thinking is more mature, their understanding of the disaster is more complete. This can result in a wide range of reactions: guilt, feelings of failure, and anger. They can also understand what is happening and how other people are reacting. Children in this age group are concerned about their own safety and safety of family and friends. As with all children they will need more comfort and reassurance. They may become preoccupied with details of the event and want to talk about it continually.

Normal Reactions:

• Disrupted relationships with peers, acting out aggression.
• Regression into earlier behaviors.
• Depressed
• Angry
• Guilty
• Difficulty sleeping.
• Manifesting fear and anxiety as physical complaints.
• Exaggerated fears.
• Feelings of rejection.
• Fears of "going crazy."
• Difficulty organizing time.
• Problems concentrating in school, with a drop in grades.
• Preoccupation with the loss, death tragedy and want to talk about it continually.

Ways of Helping:

• Be sure to talk with your child.
• Be honest with them about the events.
• Tell them what you know without exaggerating or overreacting.
• Don't assume that they are too young to know what is happening.
• Limit television coverage for this group.
• As with all children they will need more comfort and reassurance.
• Talk about and explore what death is and what it means.
• Share personal experiences of death and dying.
• Activities: play acting, puppets, drawing and painting, sharing their experiences in groups, reading, creative writing or discussion.

By the time a child is 12 years old, death is being accepted as part of life. It is seen as something that is final and that inevitably happens to everyone. Children in this age group are very much aware of what is happening and be more interested in details e.g. the cause of death, what happens after death etc. Their reactions may fluxuate and be a mixture of earlier age group reactions and reactions that are more adult.

For the pre-adolescent and adolescent it is especially important to appear wordly, knowledgeable and experienced in the eyes of their friends and peers. They will often turn to friends instead of family to talk about what has happened and validate their anxieties and fears. Experiencing a traumatic can leave the adolescent feeling that the world is unsafe. Overwhelmed by intense reactions, teens may be unable to discuss them with their family members. Instead, they may act on scary feelings or may become more withdrawn. Jokes or humor can mask fears for this age group. If they live through and survive a traumatic event, they may feel immortal which can lead to reckless behavior and risk taking.

Normal Reactions:

Overwhelmed by intense reactions, teens may be unable to discuss them with their family members.

They may act on scary feelings or may become more withdrawn.

Jokes or humor can mask fears for this age group.

Disrupted relationships with peers

Acting out, especially aggression

Increased physical, somatic complaints

Depression lonliness

Anger

Lowered self-esteem

Guilt

Feelings of rejection

Fear

Fear that things will never get better

Fear of "going crazy."

Anxiety

Easily distracted, forgetful

Problems organizing time, decline in school work.

Ways of Helping:

• Be willing to have serious discussions.
• Be honest with young adults and let them know what is happening e.g. anticipated or accidental death, tragedies.
• Acknowledge the emotions they may be feeling—fear, sadness, and anger.
• Reassurance that everything is being done and they will be cared for.
• Encourage them to express their feelings.
• If the young adult turns to making jokes as a coping strategy, let them know you do not find the jokes funny without lecturing them.
• Be available when they are ready to talk.
• Emphasize the present.
• Let them help in planning a memorial, doing something to remember the loss.
• Activities: play acting, puppets, drawing and painting, sharing their experiences in groups, reading, creative writing or discussion.
• At school: general classroom activities, literature or reading, peer helpers, health class, art class, speech/drama, social studies/government, history.

Mid-to-older adolescents and young adults have developed a more personalized view of death. However, this group is particularly more vulnerable to experiencing loss, death and tragedy because they are experiencing so many other losses and life changes. Most older adolescents are adjusting to losing their childhood and childhood friends, as they gain independence by become young adults. This group is planning for the future, leaving home, making their own decisions, living on their own and all of the changes that come with independence.

High school aged adolescents and young adults will often turn to their friends instead of family to talk about what has happened. It is important for the high schoolers to know that their parents will be available when they are ready to talk. In situations such as highly publicized disasters e.g. September 11, 2001, Columbine, etc. the high schooler may want to watch the television coverage to follow the latest news. It is important for parents to be honest with these young adults, talk to them and let them know what is happening. It can be helpful for parents to share their own feelings regarding the loss, death or tragedy, especially if it is a situation that has also affected the parents. Invite the high school to share their ideas and feelingss.

Normal Reactions:

• Feeling guilty
• Anger
• Escape with high risk behaviors e.g. sex, drugs, alcohol.
• Increased risk taking to reduce anxiety, to prove that they are alive.
• Hyperaggressive
• Defiance
• Increased physical, somatic complaints
• Cutting class
• Avoiding friends
• Increasing time spent with family
• Suicidal thoughts
• Difficulty organizing time.
• Problems concentrating in school, with a drop in grades.
• Fear of close relationships.
• Fear of "going crazy."
• Acting as though they don't care.
• Making jokes

Ways of Helping:

• Be willing to have serious discussions.
• Be honest with young adults and let them know what is happening e.g. anticipated or accidental death, tragedies.
• Acknowledge the emotions they may be feeling—fear, sadness, and anger.
• Reassurance that everything is being done and they will be cared for.
• Encourage them to express their feelings.
• If the young adult turns to making jokes as a coping strategy, let them know you do not find the jokes funny without lecturing them.
• Be available when they are ready to talk.
• Emphasize the present.
• Let them help in planning a memorial, doing something to remember the loss.
• Activities: play acting, puppets, drawing and painting, sharing their experiences in groups, reading, creative writing or discussion.
• At school: general classroom activities, literature or reading, peer helpers, health class, art class, speech/drama, social studies/government, history.

American Academy of Child and Adolescent Psychiatry. Fast Fact # 8. Children and Grief. Updated November 1998. Available at: http://www.aacap.org/publications/factsfam/grief.htm .

American Academy of Child and Adolescent Psychiatry. Fast Fact #36 . Helping Children After a Disaster. Updated March 2000. Available at: http://www.aacap.org/publications/factsfam/disaster.htm .

National Cancer Institute. Loss, Grief, and Bereavement (PDQ®) Last updated January 2001. Available at: http://www.cancer.gov/cancer_information/coping . Follow link to Loss, Grief, and Bereavement under End-of-Life Issues. Versions available for patients and health care professionals.

National Institute of Mental Health. Helping Children and Adolescents Cope with Violence and Disasters. Available at: http://www.nimh.nih.gov/publicat/violence.cfm .