Review Article

Understanding Grief in Children: Journal of Indian Association for Child and

Adolescent Mental Health
21(2) 122–129, 2025
A Narrative Review © The Author(s) 2025
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DOI: 10.1177/09731342251328150
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Suhas Chandran1, Vijaya Raman1 and Lakshmi Shiva2

Abstract
Purpose of Review: Grief in children and adolescents is uniquely different, depending on their developmental stages and
level of understanding. It may occur due to the death of a loved one, or due to other intangible losses such as moving out
of a neighborhood. Grief is not often expressed spontaneously by children, which leads the caregiver to believe that the
child is coping well with the loss. Unanticipated deaths, preexisting psychological vulnerabilities in the child and inadequate
coping mechanisms in the existing caregivers lead to more severe grief reactions. The following article is a narrative review
describing grief in the younger population, along with developmental contexts, role of culture, complex presentations of grief
and an overview of management.
Collection and Analysis of Data: Developmental considerations form the core of identifying, evaluating, and treating
grief. Contrary to what is believed, even infants can identify the loss of the caregiver and react to the loss. Secondary losses
such as a change in lifestyle also impact significantly. Grief in children with developmental disorders is often misinterpreted,
as grieving children may not be able to communicate or understand their own distress. Grief may also result in somatization
and conversion reactions.
Conclusion: It is important to identify grief in children and adolescents, especially in recent times, due to increased
unexpected deaths due to the COVID-19 pandemic, leading to bereavement in many children and adolescents. Interventions
for grief are necessary to prevent consequences such as complicated grief, increased severity of depression, post-traumatic
stress disorder (PTSD), poor socio-occupational functioning, substance use and self-harm.

Keywords
Grief in children and adolescents, developmental considerations, complex presentations in children, treatment of
childhood grief

Submitted: 06 October 2024; revised: 30 August 2024; accepted: 20 February 2025

Background this loss.3 Grief due to parental loss prior to age 18 has also
led to long-term consequences as per a longitudinal study of
Grief in children and adolescents can be distinctly different from 7 million people in Scandinavia, who remain at increased risk
that in adults, and can often be misinterpreted as stress, anxiety, of suicide for at least 25 years.4
depression, adolescent moodiness, part of developmental disor- Data concerning the incidence and prevalence of childhood
ders, and behavioral disturbances. The different developmental and adolescent grief are lacking in the Indian population but can
stages entail different levels of understanding of the concept of be expected to have similar or increased rates, considering a higher
death. In addition, the nature of the relationship with the bereaved overall mortality rate compared to developed countries.
(parent vs. extended family), suddenness of loss, and traumatic
losses (accidents, disasters) can also influence the presentation of Department of Psychiatry, St John’s Medical College, Bangalore, Karnataka,
1

India
grief in children.1 2
Centre for Advanced Research and Excellence in Autism and Developmental
About 4% of young people in Western countries experi- Disorders, St John’s Research Institute, Bangalore, Karnataka, India
ence the death of a parent before the age of 18.2 According to
Corresponding author:
the United States (US) Census Bureau, about 1 in 20 children
Lakshmi Shiva, Centre for Advanced Research and Excellence in Autism
below the age of 18 have experienced the death of one or both and Developmental Disorders, St John’s Research Institute, Bangalore,
parents.3 About 70,000-75,000 children die each year in the Karnataka 560034, India.
US, most of whom have siblings who have to contend with E-mail: dr.lakshmi0402@[Link]

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Chandran et al. 123

Table 1. Common Myths and Platitudes About Grief in Children.5,9,10 grief in children and adolescents. (b) Types of grief and
complex presentations. (c) Developmental considerations for
• 
Young children are highly resilient, do not grieve as deeply as
assessing grief in children. (d) Outcomes of grief in children.
adults
(e) Treatment interventions for grief.
• 
They are in general too young to understand about death
In addition to the information obtained from various arti-
• 
They should be protected from the pain of thinking about
cles, other novel clinical perspectives have been incorporated
death, as youth is a time free of pain and sorrow, and its
innocence should be maintained into the present article, gleaned from personal experience
• 
Bereaved children get over grief very soon and move on easily of the authors in working with children and adolescents and
• 
Grief is seen only in the context of death of a loved one their families dealing with grief.
This current review did not explore in depth, grief associ-
ated with end-of-life care for children, grief in the contexts of
Notwithstanding the inadequate epidemiological data, refugee children and those who have been victims of war-re-
there are many prevailing myths and misconceptions which lated trauma, grief in children who have been orphaned and
make the identification and management of grief in children child & adolescent homicide survivors. We have also not
and adolescents difficult (Table 1). described the impact of social media and the internet on
In spite of the significant impact grief can have on children grieving in children and believe that along with all the above
and adolescents, very little time is dedicated to training medical these should be areas of future study and review.
students and postgraduates in the assessment and management
of grief, especially during critical periods of development. This Grief in Children and Adolescents
review aims to provide students and practitioners (psychiatrist/
What Causes Grief?
clinical psychologist/pediatrician/other health care provider) with
the foundational knowledge and skills to communicate effectively The concept of “grief” cannot be limited to the death of a
about death, loss, appreciate socio cultural factors associated with loved one but is a natural response to any kind of loss.5
grief, identify diverse ways grief can manifest across develop- In children, this loss may be in the form of death of parents,
mental stages, strategies to ensure long-term consequences such siblings, grandparents, significant family or friends, pets; loss
as unresolved/complicated grief can be prevented, and to facilitate of intact families through separation, divorce; the loss of
adaptive grief interventions for children and their families. home, neighborhood, friends, teachers and school due to
moving; the loss of a loved one to incarceration/addiction/
homelessness; moving away of a sibling to higher studies;
losing a favorite possession or toy; death of a celebrity or role
Materials and Methods
model (e.g., Sushant Singh Rajput/Kim Jong-Hyun); break
Search Strategy. Study Selection, and Data Extraction up of a romantic relationship or peer group.
Grief can also occur in children suffering from chronic,
Electronic searches of MEDLINE, PubMed, and Google debilitating or terminal illnesses in the form of loss of connec-
Scholar were carried out from inception till December 2023. tion with school, peers and family due to symptoms, missing
We used the following search terms which included combina- classes, activities such as art, sports and music due to prolonged
tions of MeSH or free text terms—“grief in children and ado- hospital admissions, disruption of developmental trajectories
lescents,” “developmental considerations for grief in children,” in social, educational and home spheres. Grief can also occur
“assessing grief in children,” “impact of grief of children on the for the loss of physical capacity, prior appearance, and bodily
family,” “social and cultural factors in grief in children,” “grief integrity.5 It is both a cognitive and emotional necessity for
in children with neurodevelopmental disorders,” “grief in chil- children and adolescents to grieve.
dren and COVID 19,” and “interventions for grief in children.”
Reference lists of generated articles were also hand searched to Common Grieving Mechanisms and Processes
ensure completeness. Grief may not often be expressed spontaneously by children,
Inclusion criteria were English language articles with as children often recognize that their questions make adults
full text, which discussed grief in children and adolescents. uncomfortable, and do not pursue such discussions.
We excluded articles without full text and which did not They may assume that the questions were inappropriate, in
specifically focus on children and adolescents. Case studies case the adult reacts with sadness or distress. They may worry
were also excluded. that they may lose other adults the same way they lost this
Searches were done by all authors independently, and the loved one. Oftentimes, children may offer support to grieving
final list of articles was decided by discussion and consensus. adults, which can impress upon the caregiver that the child is
The initial search yielded 886 articles, of which relevant coping well and does not need assistance.6
English language articles with full text were examined, and Some thought processes occur commonly to grieving
33 articles were chosen for this narrative review, analyzed, children following a loss. The first consists of a shift in self-
and synthesized as the following themes: (a) Causes of concept: Did I cause this to happen? Children may view the
124 Journal of Indian Association for Child and Adolescent Mental Health 21(2)

loved one’s death as a desertion. There may also be a sense of It is suggested that professional intervention is required when
ineffectuality in controlling life events occurring in relation to grief persists longer than that expected by the cultural norms
self and immediate family: Why couldn’t I stop it? There may and evidence-based expectations, and when it disrupts the
also be identification with the bereaved. The child may emulate natural progression from acute to integrated grief or starts
the qualities of the bereaved, which may be an unconscious becoming maladaptive.
defense mechanism. Denial and idealization are other defense
mechanisms commonly employed by grieving children.1 Will it Childhood Traumatic Grief (CTG)
happen to me too? is a common question which occurs to many Cohen et al. describe a form of grief which occurs after cer-
children, along with worry about the future and the surviving tain types of loss, such as violent/unexpected deaths during
caretaker: Who will take care of me now?. Some children are also natural disasters, terrorism, war, homicide or suicide.
unable to move beyond the idealization of their parent after their Here, maladaptive patterns of grief which contain symptoms
death, often unable to free themselves to build their own identity of unresolved grief, PTSD, along with depressive symptoms
or “become their own man/woman” and continue to underplay develop. Unusually, such symptoms may also occur in losses
the parent’s limitations, even when they had been mistreated by which are not conventionally “traumatic.” Nonetheless, these
the parent and sometimes adolescents continue to use this pattern symptoms need to be addressed irrespective of the type of
in their other relationships with peers and partners. loss, first targeting the trauma symptoms and then moving
towards grief-related symptoms.11
What Makes Some Children More Vulnerable than Others?
A population-based longitudinal study found that the type of Anticipatory Grief
death (unanticipated, homicide, suicide), preexisting psycho- Described as a response to the threat of death rather than the
logical vulnerabilities in the child or existing parent contrib- death itself, it focuses on the past and present losses in addi-
uted to more severe grief reactions.7 Another study evaluated tion to future losses. There may be a rehearsal of death, with
the effect of parental coping in the surviving parent and found time available to accept death and resolve issues. Mourning is
that maladaptive parental coping styles had a major impact on for both the past experiences as well as the future which the
the child’s grief symptoms. The difficulties are also said to be loved one will never have. It is common in children of termi-
greater when a prior relationship with the deceased had high nally ill parents and should be identified and supported.5,11
ambivalence or high dependence.8
Disenfranchised Grief
Types of Grief
Disenfranchised grief is a type of grief that is often not socially
Uncomplicated grief is wherein the child has symptoms such validated or openly acknowledged or culturally recognized.
as sadness, distress, anger, loss of appetite, sleep disturbance, In the authors’ experience, in children this encompasses a wide
but is able to complete the mourning process and heal.5 range of situations such as the child’s expectancy of having a
Complicated grief is seen when the child is not able to sibling but mother having a stillborn/abortion, loss of an undis-
adapt to the loss. Symptoms may be similar to uncomplicated closed pregnancy in an adolescent girl, loss of the partner of a
grief but greater in intensity and duration. Certain factors culturally unsanctioned relationship, such as same sex partners,
prevent or delay the normal grief process.5 a grandparent having dementia/cognitive loss or a sibling leaving
These reactions may be chronic (persisting beyond the home for studies or a career (“sibling empty nest syndrome”).12
usual period of six months) or delayed (child may not have
comprehended the loss initially, and there is a delayed onset Differentiating Between Complicated Grief and MDD
and an overwhelming reaction). Some children may experi- At first glance, though both may appear similar, there are cer-
ence additional anxiety, depressive episodes, symptoms of tain qualitative differences which help differentiate the two. In
post-traumatic stress disorder (PTSD), along with symptoms grief, depressed mood is focused specifically on the loss, anhe-
of grief, leading to exaggerated grief reactions. On the other donia is rare, yearning or longing is prominent, anxiety and
hand, some children may manifest physical symptoms such guilt are focused on issues related to the deceased. Preoccupying
as headaches, body pains, and sometimes, exaggeration of thoughts about the loss are predominant instead of depressive
preexisting physical conditions instead of emotional symp- cognitions, and avoidance is focused on reminders of the loss
toms, called masked grief reactions.9 rather than generalized social withdrawal. Suicidal thoughts
The concept of complicated grief in children is poorly and behavior may be seen in both.5
understood even by clinicians, as evidenced by a survey in
Developmental Considerations as the Cornerstone of
which experienced clinicians participated. It showed that there
Assessing Grief
was difficulty in defining complicated grief in children, but that
intensity and duration were major defining aspects. They also During the early period of childhood and adolescence, spe-
felt that using adult criteria was inappropriate for children.10 cific reactions are highly likely to be influenced by the level
It is therefore clinically challenging to know when of development. Grief reactions are no different. The impact
to intervene or when to let grief take its natural course. of loss and trauma on children depends heavily on the life
Chandran et al. 125

stage during which the event occurs. An understanding of the and concrete language. Symptoms may present as disrupted
child’s concept of death is necessary for one to assess grief. sleep and appetite, nightmares, somatic complaints, behavioral
By two to five years of age, the concept of definitiveness changes (withdrawal, aggression), regression, learning diffi-
and irreversibility is not yet developed, there is an intense curi- culties, fluctuation about short periods of strong reaction and
osity about death, and it is often considered akin to protracted usual behavior (as though nothing has happened), and playing
sleep. By five to nine years of age, the concept of definitive- out themes to understand the changes.5,15
ness develops, but a belief that there is possibly a way out of it Preadolescents and Adolescents: Adolescents are less likely
continues to be held. By nine years and older, death is under- to accept help when offered, as they are transitioning to indi-
stood as irreversible and inevitable for all living creatures.13 viduation from the family. Emotional experiences are usually
This concept development is not necessarily fixed, and an kept private and may be discussed more with peers than family.
understanding of death may develop sooner or later. An explor- However, the need for conformity with the peer group may lead
atory study in Indian preschool children aged three to five years to a sense of isolation and make them unwilling to openly talk
revealed that many understood the universality and irreversibility about grief. There is greater cognitive capacity (abstract thinking,
of death, but few were able to comprehend non-functionality. problem solving, reasoning) which allows for rumination, over-
It was found that most people avoided talking about death to thinking and intellectual struggle (“Why me?” and the unfair-
children even when required, as they were unsure about when ness of death), with an adult approach to grief.
children start understanding the concept of death.14 Symptoms may present themselves according to internal-
Infants are able to detect the absence of caregivers—there is izing and externalizing temperaments. There may be anxiety,
a loss of the familiar person, disruption of daily routines, smells, depression, guilt, withdrawal from support systems, inability
voices, and touch of the loved one. The child is at the senso- to concentrate, hypervigilance, fear of death/violence occur-
rimotor stage, where sensory motor skills are just developing ring again, thoughts of self-harm and suicide. There may also
and there is no verbal development. Grief may therefore mani- be an increase in risk-taking behaviors, substance use, aggres-
fest itself in the form of irritability, crying, difficulty to soothe, sion, anger outbursts, delinquency, acting out behaviors and so
changes in sleep and feeding patterns, withdrawal, frustration, on. They may also start questioning religious beliefs, and some
aggression, separation anxiety, and clinginess, with fear of unfa- may start exploring spirituality.5,15
miliar adults. At this stage the infant could also be reacting to
the adult’s grief or the exposure to adult distress. Impact of an Impact of Secondary Losses
emotionally unavailable parent, as in a lack of attunement and Secondary losses are the losses of aspects of life which would
attentiveness, also needs to be considered. have been contributed by the person who died, such as a
By preschool to five years, language and cognitive skills change in lifestyle (change in financial or social status),
are still immature, there is egocentric, moralistic, and magical change of city, school, loss of relationship with friends and
thinking. Being in the preoperational stage of cognitive devel- family of the person who died, less time available with the
opment, they may fail to gain abstract concepts completely, surviving parent, who may have to take on more responsibil-
and resort to concrete thinking (e.g., Bad things happen to ities, loss of specific activities (the parent who died may have
bad people. I didn’t put away my toys, that’s why he died. been taking the child to sports matches and cheering for
It’s all my fault). them), a loss of safety and trust in the world in general. Some
Irreversibility and non-functionality concepts of death are losses may become tangible only years later, such as a person
not adequately developed, and questions about when the person experiencing a loss of her mother’s advice and expertise
will come back are frequent, with anger towards the deceased when her own child is born.
for delaying return, and fear of abandonment. Symptoms are
in the form of anxiety, distress, temper tantrums, aggression, The Family’s Role
regression (return to thumb sucking, loss of toileting skills) The family forms the immediate environment for the bereaved
and themes of death expressed through play and behavior.15 child, and it is important to understand the family’s position,
Primary school age: School children may be significantly as the family as a whole also grieves, which again impacts the
preoccupied with their own needs and how the loss will affect child. Interventions should take the family context into con-
them in the long run. They continue to have magical thinking, sideration. The factors to be assessed while evaluating the
and may believe that it is their fault, leading to guilt and regret. family are mentioned in Table 2.
They may start worrying about the existing caregivers, about
their health and their potential death, offer support, assume a Socio-cultural Considerations
caregiving role to the parent and sibling, inhibiting their feel- The expression of grief and mourning are different in different
ings of sadness and fear. There is concrete thinking, and vulner- cultures, in the form of various customs and rituals. Dr VK
ability to faulty beliefs (e.g., It is the hospital which caused Verma’s article “Cultural Psychodynamics in Health and
death, rather than the illness). There may be repetitive, specific Illness” talks about “cultural defences” like individual defense
questions about death (such as what happens to the body when mechanisms to cope with anxiety.19 This cultural defense can be
buried), which need to be addressed with correct information provided by customs, traditions, rituals, sanctions, prohibitions,
126 Journal of Indian Association for Child and Adolescent Mental Health 21(2)

Table 2. Key Assessments of the Child’s Family.15–18

• Has the bereavement disrupted family functioning (temporarily or longer term?)

• Has the bereavement changed family roles and responsibilities? Is this impacting on the child/adolescent’s developmental stage?
• How are the parent(s) coping? What supports do they have?
• Is there an emotionally available parent/caregiver?
• Family communication style: Are the family able to talk about and express feelings in general? Can they talk about the death and the
loss of the loved one?
• Is the child supported to process feelings of grief/supported to engage with social rituals, e.g., attend funeral? Other cultural, spiritual,
religious values and practices
• Can parent(s) show appropriate emotions, model grief to children? or is it taboo to talk about it?
• Changes in parental limit setting—Do they lack energy to set firm, consistent boundaries now; Has the parent become
overprotective?/Sympathize with child’s loss and feel unable to set boundaries
• Can the parent separate the child’s feelings from their own feelings—or is this overlapping?
• Parent depressed, irritable, unpredictable, emotionally shutdown, or hostile? Overwhelmed?
• Parent over relying on their child for emotional support?

or symbolisms, and may serve as a coping mechanism in par- ence, opportunity, and a loss of identity. Grief in children with
ticular situations. For instance, elaborate rituals exist in India developmental disorders may manifest in the form of somatic
during mourning in almost all cultures, which enables family complaints (headache, stomach pains), social withdrawal,
members to express their emotions about the deceased person increased compulsive behaviors, ritualization, and self-stimu-
and serves as a “Natural Psychotherapy” recommended for latory behaviors (hand flapping, twisting, head-banging).23
grief resolution. A few days in a year are dedicated to paying Significant secondary losses, poor communication
homage to ancestors in Hindu culture. Some cultures approach ability, poor understanding and non-development of coping
death as a celebration of life, honoring and celebrating the mechanisms leads to increased risk of pathological grief in
deceased on Dia de los Muertos (Day of the Dead).20 The these children.
beliefs of “After Life” and “Reincarnation” in some cultures
Conversion Disorder
may provide spiritual consolation that it is not the “end” for the
deceased soul. Grief converted into symptoms can often result in somatiza-
tion and conversion reactions. Recent loss of a loved one was
a contributory psychosocial factor in 12.5% of children with
Complex Presentations in Grief conversion disorder assessed in an Indian population.24 A
Grief and Developmental Disorders study evaluating conversion disorders in children found unre-
solved grief reactions in 58% of the study sample.25 Grief,
Diagnosing and managing grief in children with developmen- presenting as conversion reactions, are poorly studied.
tal disorders is a doubly challenging task, as these children may However, even with the existing research, the clinician would
not have the verbal ability to express their thoughts and emo- be justified in considering the possibility of unresolved grief
tions. This may lead to non-recognition or misinterpretation by when evaluating conversion disorders in children and
the caregiver and healthcare provider. Conversely, the grieving adolescents.
child himself or herself may not understand why the changes
are occurring, complicated by the fact that there is a limited COVID-19 and Grief
repertoire of confidantes. The limitations of language skills, Increased unexpected deaths due to the COVID-19 pandemic
cognitive difficulties, decreased or altered expression of emo- has led to bereavement in many children and adolescents,
tions are some of the biggest challenges. In addition, there may with about 2.2 children and 4.1 grandchildren bereaved for
be a learnt tendency to respond positively (pleasing people for every person who dies.26 In addition to the suddenness of the
social acceptability). Oftentimes, the child may not be informed loss, various other factors such as forced social isolation, not
about the death, or sometimes given false information, such as, being able to say goodbye to loved ones by being with them
They’ve gone on vacation/They have moved to another city. during their last minutes, loss of comfort of physical contact
Family members treat them differently, leading to an overpro- such as hugs have increased the risk of complicated or unre-
tection from death and related themes. This can lead to a solved grief. In addition to losses due to the death of near and
delayed grieving process, along with a loss of trust in the exist- dear ones, unemployment in the family, lack of food supplies,
ing caregiver.21,22 and financial concerns also contribute to complicated grief,
In addition to death or separation, these children have especially in children from disadvantaged backgrounds.27
to routinely contend with other often ignored secondary Some may even have had multiple deaths in the family.
losses such as disrupted relationships with peers and family Parents may have been unable to provide adequate support
members, loss of functioning or ability, loss of independ- due to their own losses, financial insecurities, and increased
Chandran et al. 127

responsibilities. However, it cannot be ignored that the lock- (a) persist longer than expected by cultural norms and evidence-
down had increased the time spent with family members, and based expectations, (b) disrupt the natural progression from acute
this may have contributed to improving relationships.28 to integrated grief, and (c) become maladaptive. Identifying red
flags like prolonged withdrawal, self-harm or severe changes in
Outcomes of Grief in Children and Adolescents behavior is extremely important and should warrant professional
A longitudinal study of bereaved children, adolescents and help.
their families, with yearly assessment for up to three years Encouraging open communication, providing age-
after parental death showed that 30.8% showed grief reac- appropriate information, normalizing grief reactions and
tions for more than nine months after death, after which they providing social support from the ground rules during grief
resolved. A total of 10.4% of individuals had sustained grief intervention in children. Using creative therapies like art play
reactions even after three years of death. The rest showed and music can ease the expression of emotions in grieving
rapid resolution of symptoms within one year of death. children. Supporting structured daily routines, teaching
Prolonged grief also predicted earlier onset of depression.7 coping skills through techniques like breathing exercises and
A population-based study in bereaved families with biological mindfulness can go a long way.30-32
offspring of 7-25 years of age showed that bereaved offspring One important element of the treatment process is for
and their caregivers had an increased risk of depression and the child mental health professional to work with the parents,
PTSD, and bereaved offspring had three-fold increased risk of especially when the grief is with younger children. Following
depression even after controlling for other risk factors.29 are some strategies that could be used in helping parents:5,9,33
Separation anxiety, depression, conduct disorder and substance
abuse were more likely to be seen in bereaved than non-bereaved • For pre-school children, parents should answer the
children. Another study found that bereaved youth had lower child’s questions around the bereavement in a simple
competency at work, lower peer attachment, decreased educa- yet factual manner.
tional aspirations, and less elaborate planning for future careers. • Not helpful to lie or tell half-truths, avoid confusing
These were more commonly mediated by the effect of bereave- terms and euphemisms, for example, a long sleep, on a
ment on caregiver and child functioning as well as family cli- trip, lost, etc.
mate. These outcomes were not related to the age at the time or • A few identifiable triggers—Death anniversaries,
cause of parental death or gender of the deceased parent.29 birthdays, holidays, Mother’s Day, Father’s Day, and
graduations, may be triggering events for grief.
• Prepare the child for loss where possible, for example,
Treatment Interventions for Grief illness.
• Children need to continue to develop mastery of
General Principles
their world. Provide a structured environment that is
To work in the intervention of grief, one must be aware of consistent and predictable.
one’s own grief issues, should be able to interpret the range of • Positive regard, warmth, nurturing, and affection
normal grief behaviors and permit individual differences in are important, but important to reinforce the idea to
coping strategies. In children, there may be an additional parents that love does not mean becoming permissive.
need of being there for the surviving parent while they • Emphasize to parents the need to contain acting out
reinterpret death evolving through their cognitive abilities. behavior, to not allow for school refusal to build.
Many children traverse the tasks of mourning and find • Parenting factors also need to be addressed by the
their way to integrated grief without professional assistance. mental health professional, especially overprotective-
Helping identify their personal supports/circles so they know ness, enmeshment, over-reliance.
whom to reach out to when they need to talk or emote or • Be patient with regressive behaviors (no need for
want reassurance or guidance is important. Such local “safety trigger finger responses to thumb sucking!).
nets” could include compassionate friends, peers at school, • Maybe engaging with activities with the child is better
religious organizations, school/local counselors, and teachers. than talking. Provide more opportunities for play.
These could be sources of active listening and granting safe • Creating linking objects—Children may fear that they
space in which they can tell and retell their stories of grief will lose memories and forget the loved one as time
until they feel the narrative is more integrated. passes, especially when they were younger, when the
The body of literature on resilience indicates it can be person died. Help memorialize and retain connec-
unproductive to introduce “grief work” to a child when it is tion to their loved ones through memory boxes, photo
not needed. For the smaller percentage of those who experience albums, family videos, keepsakes.
grief that significantly disrupts functioning in the months or • For adolescents, parents should encourage them to find
years after a death, therapeutic interventions can facilitate prosocial outlets in physical and creative activities.
more constructive coping. Professional help is often a must • Independent assessment & treatment of the surviving
when thoughts, emotions, and behaviors arise during grief that parent may become necessary in some cases.
128 Journal of Indian Association for Child and Adolescent Mental Health 21(2)

More specific interventions with the child can involve the capacity at different developmental stages. A child’s identity
following: may be affected by a loss because self-development is still in
process. Provision of active listening; education about grief—
• Explore defense mechanisms and positive and nega- its physical, psychological, and spiritual effects is vital.
tive coping styles: Important to remember that defense Primary tasks of mourning, performance of risk assessment,
mechanisms apart from serving the objective of self-pres- teaching of coping strategies are important components of
ervation, also reflect the deeply ingrained socio-cultural effective work with grieving children and families. In Indian
norms and expectations that shape the child’s actions and families, though, there would be some alternate caregiver tak-
beliefs. Changing these beliefs and generating insight ing up the responsibility of “looking after the child,” it is
must be done gradually, since breaking defense mech- often seen as a replacement of the deceased, which the child
anisms without creating alternative constructive coping may not resonate with. It becomes very important to educate
styles can be dangerous. families about handling grief in children.
• Cognitive behavioral therapy—Cognitive behavioral
strategies to help reframe negative cognitions (filtering,
personalizing, catastrophizing, and so forth), and reality Declaration of Conflicting Interests
testing or generating evidence for/against can assist The authors declared no potential conflicts of interest with respect to
with prevalent guilt. This should also involve identi- the research, authorship, and/or publication of this article.
fying avoidance behaviors and teaching to avoid avoid-
ance (there is no way through it but through it). The Funding
professional should be able to ultimately use develop-
The authors received no financial support for the research, author-
mentally appropriate language to help the child process ship, and/or publication of this article.
grief and a coherent narrative.
• To create coping skills toolboxes with the child, for use
when they feel overwhelmed (coping cards, emotion Statement of Informed Consent and
regulation strategies). Ethical Approval
• Play therapy—This could involve a variety of play The research study uses publicly available secondary literature and
materials available such as art supplies, blocks, dolls, data; thus, it did not require any ethics approval or participant con-
puppets, rescue vehicles, and medical kits, to name a sent.
few. Children often use these “props” to play out their
versions of the death scene. Some play therapists are ORCID iD
directive and ask children to play with specific play Vijaya Raman [Link]
materials and to show (with the toys) how the person
died: Others are non-directive and instruct children to
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