Special vigilance is required in environments where death poses a risk to the normal development of grief in childhood, such as the mental illness of a family member, limited family and/or friend support, the sudden or prolonged illness-related death of a loved one, accidental deaths, among others (Artaraz Ocerinjaúregui et al., 2017). These factors can complicate the grieving process and may indicate the child needs additional support, especially if a change in behavior or personality is observed after the loss (American Academy of Pediatrics and Children’s Hospital of Philadelphia, 2021). However, according to Artaraz Ocerinjaúregui et al. (2017), the label "pathological" should be avoided until strict diagnostic criteria are met, to prevent pathologizing what may be a normal grieving process that can be overcome without specialized intervention.
After losing a parent, up to 35% of children under 12 show signs of depression within a year (Artaraz Ocerinjaúregui et al., 2017). Before considering grief as complicated, it is advisable for both the child and their family to allow time to start the process, accept the new reality, and face the inevitable difficulties that will arise. Additionally, according to Artaraz Ocerinjaúregui et al. (2017), it is important for the child to have the opportunity to integrate the loss and the relationship with the deceased into their personal history, with the support of their family and educational environment.
To determine whether it is necessary to seek professional help, certain guidelines, although not infallible, can serve as orientation (Artaraz Ocerinjaúregui et al., 2017). It is recommended to consult a specialist if any of these situations occur: the loss is highly significant because the deceased had an important role in the child’s or adolescent’s daily life and their death will cause many changes in the family, or the loss is very impactful due to the circumstances in which the death occurred. In line with Díaz (2016), reactions that appear after the loss prevent the child from leading a normal life.
Up to Six Years Old
Reactions in children up to 6 years old after a significant loss can be diverse (Artaraz Ocerinjaúregui et al., 2017). They may show an inability to perform tasks they previously did independently, such as sleeping alone, turning off the light, or giving up their pacifier. There may be constant and exaggerated crying that doesn’t stop. Persistent separation anxiety can also arise, manifesting in reluctance to participate in activities that involve separation from the caregiver, either out of fear something might happen or fear of another abandonment (Artaraz Ocerinjaúregui et al., 2017). In such cases, according to Díaz (2016), children may avoid games or activities to spend more time with their primary caregivers.
Additionally, debilitating fears and terror towards everyday things that didn’t exist before can appear (Artaraz Ocerinjaúregui et al., 2017). These fears may relate to death, changes, cars, illnesses, darkness, ghosts, among others (Díaz, 2016). Sleep problems such as prolonged insomnia or recurring nightmares may occur (Artaraz Ocerinjaúregui et al., 2017). Consequently, they may not want to stay alone in their room and tend to get into their parents’ bed (Díaz, 2016). If one of the caregivers has died, they often want to sleep with the surviving parent, and once this happens, it can be very difficult for them to return to their own room (Díaz, 2016). Depressive symptoms such as apathy, deep sadness, and refusal to engage in enjoyable activities may also arise (Artaraz Ocerinjaúregui et al., 2017). Finally, according to Artaraz Ocerinjaúregui et al. (2017), they may show a refusal to eat and significant weight loss.
From Six Years Old
From the age of six, various reactions can be observed in children after a significant loss (Artaraz Ocerinjaúregui et al., 2017). One reaction may be isolation, where they shut down communication. Extreme social isolation can also emerge, where they do not want to interact with others because they believe they won’t be understood. Emotional numbness, where they are barely able to express emotions associated with the death, may also occur. Additionally, according to Artaraz Ocerinjaúregui et al. (2017), they might assume excessive responsibility or collaboration after the death, developing an exaggerated tendency to take care of others.
Persistent symptoms of anxiety and nervousness in their daily activities may appear (Artaraz Ocerinjaúregui et al., 2017). Similarly, they may show constant irritability and aggressiveness, including aggression towards their peers (Artaraz Ocerinjaúregui et al., 2017). They may become more violent in play, respond angrily, lose their temper easily, and destroy things they previously did not (Díaz, 2016). Depressive symptoms such as insomnia, regression to earlier stages, apathy, and loss of interest in previously enjoyed activities may persist (Artaraz Ocerinjaúregui et al., 2017). According to Artaraz Ocerinjaúregui et al. (2017), they may show a drastic reduction in activity, with no desire to participate in anything.
They may also have difficulty reintegrating into the academic environment, with prolonged concentration problems, and a significant, sustained drop in school performance (Artaraz Ocerinjaúregui et al., 2017). This may include difficulty attending school, new complaints about school, or discomfort at leaving home (Díaz, 2016). Prolonged fears and separation anxiety that do not cease may also be present (Artaraz Ocerinjaúregui et al., 2017). Finally, according to Artaraz Ocerinjaúregui et al. (2017), they may show persistent somatization without a medical explanation, such as headaches, stomachaches, vomiting, and muscle pains.
In Adolescence
In adolescence, various reactions can arise after a significant loss (Artaraz Ocerinjaúregui et al., 2017). However, adults around the adolescent should be guided by the degree of interference it causes: if minor issues do not interfere significantly, it is usually advisable to allow time to see if normalization occurs, understanding that these are logical reactions to death (Díaz, 2016). According to Díaz (2016), in cases where interference is a problem, it is important to intervene to help the adolescent regain their routines and habits as soon as possible.
They may feel anger towards those who delivered the news or towards healthcare professionals who couldn’t do more, blaming them directly for the death (Artaraz Ocerinjaúregui et al., 2017). Recurrent negative thoughts about death that do not stop, and engaging in risky behaviors because life has ceased to matter to them, may occur. Suicidal ideation that leads to the formulation of a suicide plan may also arise. Additionally, depressive symptoms may persist, they may feel relentless guilt, and exhibit sustained reactions of inappropriate enthusiasm or joy. They may begin or increase substance use (Artaraz Ocerinjaúregui et al., 2017). They may also struggle to return to their usual routines.
A notable reaction is a significant drop in academic performance, provided this was not a pre-existing issue (Artaraz Ocerinjaúregui et al., 2017). Problems related to attention, concentration, exam anxiety, academic disinterest, and errors may arise after the death (Díaz, 2016). Extreme isolation may also be observed (Artaraz Ocerinjaúregui et al., 2017). According to Díaz (2016), adolescents may be reluctant to participate in social events they used to attend and spend time with peers, reduce their leisure activities, stay with adults, or take on responsibilities they previously didn’t.
Another behavior that may emerge is assuming responsibilities they did not have before, which can affect their social life (Artaraz Ocerinjaúregui et al., 2017). They may also avoid touching the deceased’s belongings, preferring to leave everything as if the person were going to return. Additionally, somatic complaints related to the deceased’s illness may arise (Artaraz Ocerinjaúregui et al., 2017). These may involve minor ailments requiring medical attention, such as headaches, abdominal pain, gastrointestinal issues, and general discomfort (Díaz, 2016). Finally, according to Artaraz Ocerinjaúregui et al. (2017), other somatic, obsessive, anxiety, and separation disorders may appear, which were previously non-existent or insignificant.
References
American Academy of Pediatrics and Children’s Hospital of Philadelphia. (2021). El Duelo en la Infancia: Cuándo Buscar Ayuda Adicional. Healthy Children. https://www.healthychildren.org/ Spanish/healthy-living/emotional-wellness/Building-Resilience/Paginas/Grieving-Whats- Normal-When-to-Worry.aspx
Artaraz Ocerinjaúregui, B., Sierra García, E., González Serrano, F., García García, J. Á., Blanco Rubio, V., & Landa Petralanda, V. (2017). Guía Sobre el Duelo en la Infancia y la Adolescencia: Formación para madres, padres y profesorado. Colegio de Médicos de Bizkaia. https:// www.sepypna.com/documentos/Guía-sobre-el-duelo-en-la-infancia-y-en-la-adolescencia-1.pdf
Díaz, P. (2016, febrero 25). Signos de Alerta que Indican Cuándo Llevar a los Niños a Terapia de Duelo. Fundación Mario Losantos del Campo. https://www.fundacionmlc.org/signos-cuando- llevar-ninos-terapia-duelo/
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