Children and Bereavement

Bereavement in childhood is a significant public health issue. Children affected by the serious illness or death of someone close — a parent, sibling, grandparent, or caregiver — are at increased risk of emotional, behavioural, and academic difficulties. In Australia, an estimated 1 in 20 children will experience the death of a parent before reaching adulthood, and many more will lose a sibling, grandparent, or other close figure. The impact of bereavement is shaped by the child's developmental stage, the nature of the relationship, the circumstances of the death, the quality of surviving support, and the child's own temperament and resilience.

Palliative care in Australia encompasses anticipatory grief and post-death bereavement support as integral components of holistic care. The National Palliative Care Strategy (2018) recognises that families — including children — are unit of care, and that bereavement support should begin before the death occurs. Paediatric palliative care services, such as those at the Royal Children's Hospital Melbourne, Bear Cottage (Sydney), and the Queensland Paediatric Palliative Care Service, provide family-centred bereavement care.

Australian data from the Australian Institute of Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS) indicate that approximately 4,500–5,000 children under 18 lose a parent each year. When siblings, grandparents, and other significant figures are included, the number of bereaved children is substantially higher. Aboriginal and Torres Strait Islander children are disproportionately affected due to higher rates of premature mortality, chronic disease burden, and the cumulative impact of intergenerational grief.

This guideline provides Australian clinicians — general practitioners, paediatricians, palliative care specialists, nurses, psychologists, social workers, and school counsellors — with evidence-based guidance on supporting children through bereavement, from the period of anticipatory grief through to long-term adjustment.

Children's conceptualisation of death evolves with cognitive, emotional, and psychosocial development. Clinicians and families must understand these developmental stages to communicate effectively and provide appropriate support. The following framework is based on the work of Worden (1996), Corr & Corr, and the Childhood Bereavement Estimation Model, and is widely applied in Australian paediatric palliative care practice.

Worden's Tasks of Mourning in Children

William Worden (1996) described four tasks of mourning adapted for children, which remain a useful clinical framework in Australian practice:

1. To accept the reality of the death — children may need to be told repeatedly, in concrete language, that the person has died and will not return.
2. To process the pain of grief — children need safe outlets for emotional expression; not all children will express grief verbally — play, art, and physical activity are valid expressions.
3. To adjust to an environment without the deceased — this may involve new routines, changed living arrangements, or shifting family roles.
4. To find an enduring connection with the deceased while embarking on a new life — maintaining bonds through memory, ritual, and storytelling while allowing new relationships and experiences.

One of the most important roles for clinicians and families is helping children understand what is happening. Clear, honest, age-appropriate communication reduces anxiety, builds trust, and supports healthy grief adjustment. Research consistently shows that children who are told the truth about a death — in language they can understand — have better long-term outcomes than those who are excluded from information or given euphemistic explanations.

Core Principles of Communication

Age-Specific Language Guide

When the Death is by Suicide

Deaths by suicide require particular care. Children should be told the truth, but in an age-appropriate and carefully framed way. For school-aged and older children: "[Name] had an illness in their brain called depression that made them feel so unwell that they died by suicide." Emphasise that it was the illness, not the child or anyone else, that caused the death. For preschoolers, a simpler explanation may suffice initially, with more detail added as the child grows. Referral to specialised bereavement support (e.g., StandBy Support After Suicide, Kids Helpline) is recommended for all families bereaved by suicide.

A common question from families is whether children should visit a dying loved one — in hospital, in a palliative care unit, or at home. The evidence supports offering children the choice to visit, provided they are adequately prepared, accompanied by a trusted adult, and given the option to leave at any time. Forcing or forbidding visits can both be harmful.

Guiding Principles for Visits

• It is the child's choice. Children should never be forced to visit, nor should they be told they cannot. Present the option honestly: "Would you like to see Grandpa? He is very sick and looks different than usual. We can go together, and if you want to leave, we will."
• Prepare the child. Describe what they will see, hear, and smell. "Mum is sleeping a lot now. She has some tubes connected to her to help her. She may look thinner than you remember. The room may smell different." This reduces fear of the unknown.
• Designate a support person. This should ideally be someone other than the most grief-stricken family member — a grandparent, family friend, or healthcare worker who can focus on the child's needs.
• Have an exit plan. Let the child know before the visit: "If you feel scared or want to stop, just tell me and we'll go outside straight away." Provide a comfortable alternative space nearby (playroom, garden, café).
• Keep visits short and child-led. Even a brief visit — 5 to 15 minutes — can be meaningful. Some children may wish to sit quietly, draw a picture, read a story, or simply be in the room. All of these are valid and valuable.
• After the visit. Talk to the child afterwards in simple terms: "What did you notice? How did that make you feel? Do you have any questions?" Normalise any reactions.

Specific Considerations

Children at the Time of Death

Some families wish for children to be present at the moment of death. This is a deeply personal decision and there is no universal right or wrong answer. If a child wishes to be present and the family is supportive, ensure a dedicated support person is available to attend to the child. Discuss with the child beforehand what may happen, including changes in breathing and the possibility that the person may not respond. After the death, provide the child with time to say goodbye if they wish, and ensure ongoing support in the hours and days that follow.

The family and school environments are the two primary contexts in which children experience and process grief. Coordinated support across both settings is essential for optimal adjustment.

Family Support Strategies

• Maintain routines. Regular mealtimes, bedtimes, school attendance, and extracurricular activities provide structure and normalcy during a period of upheaval. Routine is one of the strongest protective factors for bereaved children.
• Keep communication open. Families should be encouraged to talk about the deceased person, share memories, and answer questions honestly. Avoidance of the topic can signal to children that grief is shameful or that the person should not be remembered.
• Monitor the surviving parent/caregiver. A bereaved parent's own grief may impair their capacity to attend to their children's needs. Assessing parental wellbeing and connecting parents with their own support services is an important part of child-focused bereavement care.
• Involve extended family and community. Grandparents, aunts, uncles, family friends, and community members can provide practical and emotional support. Be alert to families who are socially isolated.
• Create rituals and memory-making opportunities. Memory boxes, photo albums, planting a tree, writing letters, lighting candles, or visiting significant places can help children maintain a continuing bond with the deceased. Many Australian hospitals and palliative care services offer memory-making programs.
• Use age-appropriate resources. Books such as "The Invisible String" by Patrice Karst, "Beginnings and Endings with Lifetimes in Between" by Bryan Mellonie, and "Ida, Always" by Caron Levis are used widely in Australian settings. The Feelings Library (Kids Helpline) and Feelings Flashcards (Childhood Bereavement Network) are also useful tools.

School Liaison and Support

Schools are a critical support system for bereaved children. With the family's consent, communication between the clinical team, family, and school enables a coordinated approach.

• Notify the school. Encourage families to inform the child's classroom teacher, year coordinator, and school counsellor. Provide basic information (without breaching confidentiality) about the circumstances of the illness or death.
• Alert teachers to behavioural changes. Teachers should be aware that bereaved children may show changes in concentration, mood, behaviour, social interaction, and academic performance. These are normal grief responses, not misbehaviour.
• Establish a "safe person" at school. Identify a trusted teacher, counsellor, or support staff member whom the child can approach if distressed during the school day.
• Provide flexibility. Bereaved children may need modified homework expectations, permission to leave class if overwhelmed, or access to the school counsellor without prior appointment. Some schools offer formal bereavement plans.
• Manage disclosure sensitively. The child should have input into what information is shared with peers. Older children and adolescents may prefer to manage disclosure themselves; younger children may need the teacher to explain to classmates in general terms.
• Special dates and events. Be aware of Mother's Day, Father's Day, family tree projects, Christmas concerts, and graduation ceremonies — these can be especially difficult for bereaved children. Offer alternatives or modifications proactively.

Australian School-Based Programs

When to Refer for Specialist Support

1. 1. Worden JW. Children and Grief: When a Parent Dies. New York: Guilford Press; 1996.
2. 2. Bluebond-Langner M. In the Shadow of Illness: Parents and Siblings of the Chronically Ill Child. Princeton: Princeton University Press; 2000.
3. 3. Kreicbergs UC, Lannen P, Onelov E, Wolfe J. Parental grief after losing a child to cancer: impact of professional palliative care. J Clin Oncol. 2007;25(12):1563-1569.
4. 4. Australian Institute of Health and Welfare. Palliative care services in Australia. AIHW; 2023. Available from: aihw.gov.au.
5. 5. Australian Government Department of Health. National Palliative Care Strategy 2018. Canberra: Commonwealth of Australia; 2018.
6. 6. Corr CA, Corr DM. Hospice and Palliative Care: Interdisciplinary Perspectives. London: Routledge; 2018.
7. 7. Australian Indigenous Doctors' Association. Social and Emotional Wellbeing Framework. Canberra: AIDA; 2020.
8. 8. Royal Australian College of General Practitioners. Mental health and the Aboriginal and Torres Strait Islander community. RACGP Position Statement. Melbourne: RACGP; 2021.
9. 9. Janssens A, Deboutte D. Screening for psychopathology in child and adolescent survivors of sudden parental death: a controlled follow-up study. Arch Dis Child. 2009;94(9):685-690.
10. 10. Childhood Bereavement Network. Key facts and figures about bereaved children. London: Childhood Bereavement Network; 2022.
11. 11. Christ GH, Christ AE. Current approaches to helping children cope with a parent's terminal illness. CA Cancer J Clin. 2006;56(4):197-212.
12. 12. Thirrili. Postvention support for Aboriginal and Torres Strait Islander communities. National Indigenous Critical Response Service; 2023. Available from: thirrili.com.au.
13. 13. Dowdney L. Annotation: childhood bereavement following parental death. J Child Psychol Psychiatry. 2000;41(7):819-830.