This discussion of clinical issues and intervention strategies focuses on three subgroups of children, each with a different context for confronting death. First are children who encounter death in the course of “normal” life events, but who are not directly confronting a significant personal loss. Second, the circumstances of children with their own life-threatening illness are addressed. In such instances, a variety of special factors demand attention, including the child's awareness of his or her own condition. The third subgroup is those children who are bereaved by the loss of a parent, sibling, or other significant person. Although the thrust of clinical work and the nature of the interventions proposed necessarily differ for each of these subgroups, common developmental responses to death, loss, and grief can be identified.

Early classics in what has become a substantial body of literature regarding children's conceptions of death and loss are studies by Anthony (1940) and Nagy (1948). Both represented initial attempts to address children's awareness of death from a systematic, age-related, developmental perspective and provided support for the theory that such conceptions follow a stepwise progression. Although each study had major sampling problems, together they represented nearly the whole body of material on the topic for two decades. As a result, many writers simply accepted and repeated these early findings without question or additional investigation (e.g., Kübler-Ross, 1969, pp. 178–179). Affective, social, environmental, and cognitive variables in shaping children's unique reactions were not identified.

Subsequent research has provided firm empirical documentation that children's response to death is strongly determined by the manner in which the death concept develops. The specific concerns and fantasies expressed by children of different ages with respect to death are reflective of their cognitive understanding about it. A Piagetian framework has been applied to demonstrate how children's responses to questions about death reflect their level of cognitive development (Koocher, 1981, 1046 1985). Other developmental studies have documented acquisition of the universality and irrevocability of death concepts (Jenkins & Cavanaugh, 1985/1986; Orbach, Talmon, Kedem, & Har-even, 1987; Worden, 1996), as well as highlighting children's own awareness of their potential death (Sourkes, 1982, 1995; Spinetta, 1974). These studies suggest that the egocentrism and magical thinking characteristic of preoperational thought dominate concerns about death in young children. Young children's conceptualizations are limited by their own reality. Death is therefore considered solely in terms of the child's experiences by analogy with sleep, separation, and injury. At this stage, children are not yet able to regard death as an irreversible process, and they are most worried about the duration of separation from loved ones that death implies.

With the arrival of concrete operations at about age 6 or 7, children can distinguish self from others, become capable of comprehending the experiences of other people, and thereby recognize the permanence of death. However, the child may still think of death as something that occurs as a specific consequence of illness or injury rather than as the outcome of a biological process. When children become capable of concrete operations, they are able to use information gleaned from the media, from peers, and from parents in forming their impressions. The child's predictions gradually become more accurate over time. At this stage, youngsters are most concerned with issues of pain and inflicted injury, although separation concerns remain an issue as well.

The onset of adolescence brings formal operational reasoning and the ability to make use of abstract reasoning. For the first time, the child is able to truly realize that what is may differ from what might be. Conceptions of death begin to involve more issues of uncertainty as well as theological and philosophical elements. With the onset of formal operational thought comes a more encompassing comprehension of death as a concept. An accompanying fascination with dramatic or romanticized death and suicide may also occur. . .

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