When Is Therapy Necessary for a Grieving Child?

Bereavement is the most common adverse life event experienced by youth in the United States. In fact, according to a 2020 article published in the American Journal of Orthopsychiatry, 6.6% of U.S. children (4.5 million) will experience the death of a parent before age 18. The COVID-19 pandemic has further elevated rates of childhood bereavement, particularly among Black and Latino youth. Given the prevalence of childhood bereavement, mental health professionals are now frequently faced with questions from concerned parents and caregivers about whether or not their child is “grieving in a healthy way” or, alternatively, may require therapy.

Grief is a deeply personal experience, and there is no "right or wrong" way to navigate it. Every child grieves in their own way, and their reactions can be impacted by a host of factors such as individual coping strategies, circumstances of the death, and familial support. A recent review highlights the important ways in which parents and caregivers can heavily influence how children grieve. When support is lacking, children are more at risk for developing psychological and behavioral health problems such as depression, anxiety, substance use, or academic problems.

Even with familial support, some children may require additional help to process their grief reactions and adjust to a life without the physical presence of their loved one. However, parents and caregivers are sometimes unsure of whether a bereaved child may need therapy. Recognizing the following risk markers can help to ensure that bereaved youth receive the right form of support at the right time and prevent future suffering.

Developmental regressions are among the first signs that a young child may need extra help after the death of a loved one. These regressions can include major changes in sleep, language, or eating habits and difficulty separating from adult caregivers. For example, caregivers might observe their child waking up frequently, climbing into their parents' bed every night, loss of appetite, excessive clinginess, or tearfulness upon separation. Extreme yearning or longing for the deceased person can be another critical indicator. This can manifest as difficulties in engaging in daily activities, like being able to go to school or play with peers. Caregivers might notice behaviors such as the child going to sleep crying and waking up crying, excessive tiredness and/or irritability, or a lack of motivation to participate in activities they once enjoyed.

Although many bereaved children are distressed over the absence of their loved one, they can also become preoccupied with the death itself. This can take the form of persistent worries about the way the person died or guilt that they could not do anything to save them. This preoccupation can also present as ongoing questions about how the death occurred, a desire to continuously revisit the place of death or where they last saw the person, or expressions of shame or remorse.

Another important risk marker is extreme avoidance and numbing. A child’s inability to tolerate thinking about or talking about the deceased person may be a sign of posttraumatic stress.

Other observable behaviors associated with avoidance can include staying away from people, places, or things that remind the child of the deceased or the way they died. Caregivers might also notice emotional flatness or distress whenever the deceased person is mentioned.

Risk-taking behaviors, more common in adolescents, involve engaging in dangerous activities. For example, adolescents might turn to substance abuse, reckless driving, or other risky activities as a way to cope with their grief. Other concerning behaviors in bereaved adolescents that often co-occur with these risk-taking activities include social withdrawal, aggression, violent behavior, or self-harm.

Every child grieves differently, and there is no set timeline for grief. However, if any of the above behaviors persist for longer than six months after the death, impact daily functioning, or are accompanied by expressions of self-harm or suicidal thoughts, parents and caregivers should seek a grief-informed evaluation by a mental health professional. As a first step, parents can also use a brief grief scale to determine whether a referral is indicated. Early intervention can help bereaved children navigate their grief, prevent future mental health issues, and lead healthy, happy lives, even in the face of loss.

To find a therapist, visit the Psychology Today Therapy Directory.

A version of this post also appears on the Children’s Hospital New Orleans blog.