Parental Death During Adolescence: A Review of the Literature

Abstract

While extensive research exists on parental loss in childhood and the related psychological interventions, little has been done in the adolescent population. Adolescence is a particular phase of life characterized by a singular psychological, emotional, neurological, and endocrinological development, paralleled by the process of self-affirmation and an opening toward social relationships. This complex neuropsychological phase should thus be understood independently from children and adults. The objective of this work was to review the literature studying the impacts of parental loss in adolescents. The current review identified a wide range of behavioral and emotional responses to parental death in adolescence, including depression, suicidal ideations, anxiety, insomnia, addiction and impaired function at school and home. The role of peers, school life, and family and social environment are important for the recovery from loss. More studies are required to better understand the different psychological trajectories in adolescence after parental death and tailor mental health interventions accordingly.

Introduction

According to The Childhood Bereavement Estimation Model, over 4.8 million children in the U.S. will experience the death of a parent or sibling before they reach adulthood and this number more than doubles by age 25, to 12.7 million (Burns et al., 2020). In addition, in Canada, over 203,000 of the 7.5 million children under the age of 18 are bereaved due to a close family member dying (Corak, 2001). Until now, studies on parental death exclusively experienced by the adolescent population have been limited, as most studies mix data on both children and adolescents or on both adolescents and adults (Cinzia et al., 2014; Oltjenbruns, 1991). This combination of different populations may render the data analysis biased, since adolescence is a particular phase of life with a different neurodevelopment process compared to childhood and young adulthood (Tang et al., 2019). Moreover, some studies included adolescents and adults who had experienced other types of grief, such as the death of a friend (Oltjenbruns, 1991) or were also limited to Anglo-American and Mexican American participants only, excluding other ethnicities.

The adolescent period refers to individuals between the ages of 10 and 19 years (World Health Organization, 2021) and is characterized as a time of intense change, in biological, psychological, and social development (Walsh, 2011, p. 41). Adolescence is also characterized by a particular brain neurodevelopment, the final growth of the frontal lobe; in particular, the brain stem, cerebellum, occipital lobe, parietal lobe, frontal lobe, and temporal lobe actively mature during adolescence. The frontal lobes which are involved in problem solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior complete their groth at the end of adolescence, beginning of young adulthood (Arain et al., 2013, p. 451).

Therefore, it is logical to think that a perturbation or a psychological trauma during this neurodevelopmental period can generate consequences in terms of both mental health and psychological suffering. This period is significantly different from both childhood and adulthood. While the parent/child attachment is characterized by a necessary and dependent bond, early adolescence is characterized by ambivalent expressions of dependence and independence (Christ et al., 2002, p. 1271), accompanied by a need to detach from one’s parents and family. According to the WHO Maternal, Newborn, Child and Adolescent Health Report, younger adolescents may be particularly vulnerable when their capacities are still developing but are beginning to move beyond the confines of their families. Furthermore, the life changes that occur during the adolescent years may incur health repercussions throughout adulthood as well (World Health Organization, 2012).

For these reasons, mourning the death of a parent in adolescence may be especially complicated. More specifically, as stated by Keenan (2014): “The tasks of adolescence, such as separation from parental objects (Laufer, 1966) and establishing oneself in the adolescent group (Garber, 1985) are being negotiated alongside the demanding work of mourning” (p. 26). Although therapy can guide and help the bereaved adolescent, “mourning is a lifelong process” whereby feelings of grief can re-emerge as life events unravel. Within this context of understanding adolescence as a unique period of time, unlike most studies that co-mingle adolescents and children, this review focuses specifically on isolating adolescent research from children and adult studies.

Unfortunately, while the literature clearly documents the potential negative impacts of parental loss during adolescence, there is no shared understanding of how adolescents experience this grieving process. Some psychoanalytic theories from the eighties hypothesize that the death of a parent in earlier adolescence causes a regression to a less mature state since the process of separation is interrupted by the death; while in older stages of adolescence, it can cause a “parentification”, transforming the individual into a surrogate parent, threating the independence and the complete separation from the surviving parent (Corr & McNeil, 1986). More recent studies have pointed out the complexity of responses in adolecents to the parent’sdeath, spanning from an “accelerated maturity” to the change of the vision of the world, perceiving events as random, unpredicatable and forcing the adolescent to attribute meaning to the loss during a period of personal growth (Tyson-Rawson, 1996).

Given the increasing importance of adapting counseling to adolescent needs and experiences, understanding how young people experience, process and cope with loss is critical in order to better guide this vulnerable population (Bonanno et al., 2004; Gross, 2018; Humphrey, 2009; Worden, 1982; Wortman & Silver, 2001). Within this context, this article reviews recent literature on grieving adolescents who have experienced parental loss in order to identify important themes about the grieving process and specific areas of future research needed.

Aim of the Review

The aim of this work is to review previous research on adolescents who have lost a parent (or both) during their adolescent years only, in order to aggregate what is known about the specific grief experiences of adolescents. Additionally, this review aims to identify and target specific areas where additional research could be particularly beneficial.

Methods

The methodology used to complete this review included identifying articles, reviewing them to identify relevant excerpts, aggregating those excerpts into themes, and writing a discussion that details each theme. The wide range of scales used to measure grief in the adolescent population, as well as the heterogeneity of the results of the present review, allowed for a coding system which resulted in a range of reactions to parental death, impacts of parental loss and responses to grief.

Literature Identification

A review of the literature was conducted, ranging from 1987 to September 2020, using the databases PsychMed, Scopus CINHAL and Google Scholar. This review was carried out using the following keywords: adolescent OR teen OR teenager AND grieving OR grief OR bereavement AND parental death. Retrieved articles were included if their participant populations included adolescents who had experienced parental loss during their adolescent years only. The selection of articles examined and retained was done by reading the titles and abstracts. The potentially relevant articles were then retrieved in full text, and further assessed for inclusion. References of included studies were then also reviewed to identify additional studies. After removing duplicates and excluding articles not pertaining to adolescents bereaved due to parental death, the search resulted in a final count of 36 articles that met criteria for inclusion applicable this topic (see Figure1). Details about each article are summarized in Table 1.

Table 1.

Description of Studies: Death Due to Early Parental Death.

Author, year	CTY	DES	Size	Gender	Age at time of parental death	Method of data collection	Relevant results
R. E. Gray, 1987	CAN	MX	50	M = 16F = 34	12–19	BDIS, ISSS, DDT, HTFI, IAS, Semi-structured interview	Participants expressed, due to parental death, signs of depression, increased physical symptoms, and a lower level of school grades when compared to their grades before parental death.
Raphael et al., 1990	AUS	QN	1,942	M = 1097F = 1061	14–18	SEDQ, EPI, GHQ, BIS, IS, ANOVA, OSIQ	Adolescents who have lost a parent have reported differences with those adolescents who have not experienced parental death.
Harris, 1991	USA	MX	11	M = 6F = 5	13–18	CDI, YSR, IES, TRF, CBC, BDIS, DISC, Semi-structured interview	Adolescents who experienced parental death reported a need to have closure with the deceased parent, experienced suffering in relations with friends, feeling pain and feeling isolated, as well as having problems sleeping. School problems as well as eating issues were also reported.
Kuntz, 1991	USA	QL	26	M = 15F = 11	Adolescence	Semi-structured interview	Adolescents grieve different than do children, as well as do older adolescents. Open communication, having closure with the deceased parent, and taking part in the funeral preparations appeared to be a factor in adaptive grieving.
Meshot & Leitner, 1993	USA	QN	20	M = 10F = 10	Mean = 15.7	ETGI	Anger, sleep problems, shock, sense of loss as well as irritability and dwelling on the deceased parent were found amongst participants of this study.
Munholland, 2001	USA	QL	15	n/a	Adolescence	Open-ended interview	Failed expectations of an adolescent’s existing perceptions about the deceased parent and lack of response to an adolescent’s needs as a griever significantly affects adolescent’s grieving experience.
Rotheram-Borus, 2001	USA	QN	211	M = 47% F = 53%	Mean = 15	BSI	A main finding was that female adolescents reported more emotional distress and fewer problem behaviors than male adolescents, and parental death had a pervasive effect on both emotional distress and problem behaviors.
Servaty & Hayslip, 2001	USA	QN	317	M = 25 F = 44	13–19	HSCL, MCSDS, NK tests	Interpersonal sensitivity, anxiety, and depression, as well as somatization and obsessive-compulsive behavior, were significantly linked to the parental loss in adolescent participants.
Christ et al., 2002	USA	QL	1	M = 1	14	Open-ended interview	One male adolescent felt the lack of support by his peers was a significant problem. The need to talk about the death and write about it appeared crucial for this participant.
Cait, 2004	USA	QL	18	F = 18	Mean = 14.5	Semi-structured interview	Religion and spirituality: the girls struggled with their views on religion after parental death and felt angry with God; but at the same time, they wanted to maintain a connection with the parent who died.
Cait, 2005	USA	QL	18	F = 18	11–17	Semi-structured interview	Female identity development: the girls expressed becoming the caregiver to the surviving parent, as well as replacing the deceased parent. Their identities shifted from daughter to caregivers.
Cait, 2008	USA	QL	18	F = 18	11–18	Semi-structured interview	Developing a relationship with the deceased parent, experiencing changes in roles in the family and titrated grieving were found in the participants’ interview responses.
Raza et al., 2008	USA	QN	150	n/a	16–20	MPC, ANOVA	Compared to adolescents who still had both parents living, bereaved adolescents experienced greater physical problems and greater health issues.
Dehlin & Reg, 2009	SW	QL	5	M = 3F = 2	14–17	Interview	Feeling alone in the grieving process was felt by these bereaved participants, as they felt their lives had been forever affected and made different.
Patterson and Rangganaddhan, 2010	AUS	QL	62	M = 19%F = 81%	12–23	Qualitative questionnaire	Adolescents felt they needed help and understanding when coping with their feelings and preferred talking to other bereaved individuals as it helped them grieve. They also felt a distraction from the grieving was necessary to disconnect with the death, such as having fun and taking breaks.
L. B. Gray et al., 2011	USA	QN	325	M = 50%F = 50%	Mean = 11.8	DICA-R, CDI, CDRS-R, HDRS, FHRDC	25% of the bereaved participants experienced a major depressive episode (MDE) compared to 1% of the community controls. An additional 24% of the bereaved participants experienced a sub-syndromal depressive episode, defined as 3 or 4 depressive symptoms, compared to 4% of the community controls.
Brewer & Sparkes, 2011	UK	QL	13	M = 6F = 7	Mean = 11.6	Participant observationSemi-structured interview	Sadness, fear, and anger were reported as crucial in bereaved adolescents in coping with the loss, as was enjoyment. Crucial for health professionals to consider when bereavement happens during adolescence, as these are two separate life transitions happening at the same time.
Karakartal, 2012	CY	QL	10	M = 5F = 5	Mean = 13.5	Half-structured interview	Reactions to grief such as: anxiety, sadness, continuous crying, fear, guilt, and musing about the deceased parent, as well as grave issues with concentration and a lowering of school performance were experienced by the participants. However, they also reported getting professional help, or help by the remaining parents, as well as feeling more responsible and studying more as well as turning to teachers and friends for support.
Brent et al., 2012	USA	MX	126	M = 50%F = 50%	Youth under 18	SQ, IPPA, FESE, FESDC, K-SADS-PL,SCID-I, SCID-I, LIFE, A-LIFE, ICCI, CGAS, GAS	Work, planning a career, and having future academic goals were all affected more negatively by the death of a parent in bereaved adolescents than did their non-bereaved counterparts.
Stikkelbroek et al., 2012	NL	QN	7076		Youth under 16	CIDI, DSM-IV	Parental death vs non death, adjusted for sociodemographic values and adversity (divorce, physical and psychological abuse, neglect, psychological problems in parents) Simple phobia OR = 0.71 (95% CI 0.51–0.99) and alcohol abuse OR = 0.69 (95% CI 0.49–0.68). No effects on mood disorders. This study showed that females internalized significantly.
Stikkelbroek et al., 2016			5618	T1 = 50.8%T2 = 51%T3 = 52.3%T4 = 52.3%	Mean = 11	DSM-III-R, CIDI,	This study showed that, in general, bereaved adolescents did not suffer much in the areas of mental health but are at risk for mental health issues by age 19. As well, internalizing problems within 2 years of parental death is a risk for adolescents.
Hamdan et al., 2013	USA	MX	235	M = 51.93%F = 49.7%	Mean = 17.6	CGAS, GAS, ICGRC, ADI, C-PTSD-SSI, MFQ, 34 SCARED, SIQ, BDIS, BAI, ASIQ, LEC, SRRS, FACES, WAI, SCSS, MSPSS, KCCoping questionnaireInterview	Alcohol and substance abuse were approximately 2.4 times higher in bereaved youth that in non-bereaved youth. In adolescents who lost a parent, there was an increased incidence and earlier time to onset of alcohol abuse and substance disorder comparing to non-bereaved controls RR =  2.44 (95% CI, 1.17–5.56). In particular, the risk of substance abuse was significant for youth over the age of 13 years HR = 6.68 ( 95% CI, 3.22–13.89; P < .001), those who developed a disruptive behavior disorder (HR = 7.55; 95% CI, 1.83–31.22; P = .005), and those who had greater functional impairment (HR = 0.93; 95% CI, 0.90–0.95; P < .001).Bereaved adolescent boys with disruptive behavior disorders were more likely to be subject to alcohol and substance abuse or dependence. Functional impairment in bereaved youngsters was factored in as being impacted by parental loss.
Keenan, 2014	UK	QL	1	F = 1	17	Clinical psychotherapy sessions	This study has indicated that although a treatment period can be precisely defined, this is not true of the mourning process itself. Mourning is a lifelong process.
Unterhitzenberger & Rosner, 2014	RW	QN	69	M = 36F = 33	14–18	Mini, CAPS-CA	High symptom levels of grief and depression were reported in bereaved youth.
Hollingshaus, 2015	USA	QN	663,729	M = 327,159F = 336,570	early parental death< age 19	Database study	Increased risk of suicide and cardiovascular disease (after the age of 18) was found in adolescent bereavement.Cox models showed parent death (PD) was associated with increased adult suicide risk before age 50, and with increased risk of cardiovascular disease deaths (CVD) for adults of all ages. For females, PD's positive association with suicide was stronger than with CVD before age 50.
Berg et al., 2016	SW	RBS	862,554	M = 51.8%F = 48.2%	early parental death<age 18	Database study	Small increased risks of long-term psychological health issues were found due to parental loss experienced by youth. Maternal death from natural causes was associated with a hazard ratio (HR) of outpatient care for depression HR =  1.19 (95% CI, 1.02–1.40) in men and 1.15 (95% CI, 1.01–1.31) in women, after adjustment for sociodemographic confounders, with similar effect sizes for paternal natural death. Death from external causes consistently had higher effect size compared with natural deaths, in particular the risk of hospital admissions for depression HR 3.23 (95% CI, 2.38–4.38) for men, and HR =  1.79 (95% CI, 1.30– 2.47) for women after a loss of a mother.
Hansen et al., 2016	USA	QL	9	n/a	14–18	Semi-structured interview	Continuing bonds with their deceased parent appeared in the majority of testimonials by bereaved youth.
Høeg et al., 2017	DEN	QN	2,390	M = 331F = 1465	early parental death < age 18	Database study	Bereaved participants scored significantly higher for substance use OR =  1.79 ( 95% CI 1.36–2.36) behavioral disengagement OR =  1.35 ( 95% CI 1.12–1.64), and emotional eating OR = 1.34 (95% CI 1.11–1.62), but not for self-blame OR =  1.12 ( 95% CI 0.93–1.34).
Apelian & Nesteruk, 2017	CANUSA	QL	11	M = 6F = 5	8–17	Open-ended interview	Having family and friends to grieve with was extremely important for the adolescent participants in this study. Working hard in school and being distracted by their peers, were helpful ways to be distracted by the death and allowed them to feel normal again.
Andriessen, 2018	AUS	MX	176	M = 19.94F = 80.6	12–18	AGI, HIB, DASS-21, MSPSS	In cases where a parent committed suicide, self-blame, anger, and betrayal were higher than those adolescents who did not lose a parent to suicide.
Cafferky et al., 2018	UK	QL	6	M = 1F = 5	16–18	n/a	Adolescents experienced a change in their family dynamics, a stronger relationship with the surviving parent as well as having a new role in the family with new responsibilities. They now perceive their roles as to protect each other. They also felt a sense of struggling in their adolescent years, with guilt and regret. Most adolescents felt they lacked the support needed to grieve and based this solely on their age category.
Ratnamohan et al., 2018	AUS	MX	9	n/a	11–17	SAA, TAAI, AAINarratives analysis	“Burying the past” and “reifying the past” were experienced by the bereaved adolescent refugees in this study in an attempt to continue their bonds with the deceased fathers. Despite being classified as “at risk,” they had high functioning at home and at school. Their competence and identity were reflective of their roles at home.
Hill et al., 2019	USA	QN	58	M = 48.3%F = 51.7%	12–17	PCBD Checklist, ANOVACross-sectional study	Thwarted belongingness after having experienced parental death in adolescence, was positively associated with suicide ideation among bereaved teenagers. A risk of suicide ideation was found only when associated to the thwarted belongingness, B = 0.72, SE = 0.27 (CI95% 0.19–1.25), but not with perceived burdensomeness.
Asgari & Naghavi, 2020	IR	QL	14	M = 5F = 9	14–17	Semi-structured interview	At first, experiencing the death of a father in adolescence had created extreme grief, shock, and denial in these adolescent participants. With time and while feeling a positive change was needed in their life, the participants slowly felt personal growth and regained an understanding of the meaning of their lives.
Birgisdóttir et al., 2019	SW	MX	622	M = 45.7%F = 54.3%	13–16	Study‐specific questionnaire that was developed according to well‐established routinesInterviews	An adolescent’s experience of parental loss was linked with a perceived poor family cohesion during their teenage years.Compared with non‐bereaved youths, the cancer‐bereaved participants were more likely to report poor family cohesion during teenage years (odds ratio [OR] 1.6, 95% CI, 1.0‐2.4, and 2.3, 95% CI, 1.5‐3.5, for paternally and maternally bereaved youths, respectively). This was also seen in young adulthood among maternally bereaved participants (OR 2.5; 95% CI, 1.6‐4.1), while there was no difference between paternally bereaved and non‐bereaved youths. After controlling for a number of covariates (e.g., year of birth, number of siblings, and depression), the adjusted ORs for poor family cohesion remained statistically significant.
Feigelman et al., 2017	USA	MX	Wave 1 = 20,745Wave 2 = 15,000+Wave 3 = 15,170Wave 4 = 15,000+	n/a	Wave 1 = 13–19Wave 2 = 14–20Wave 3 =  18-26Wave 4 = n/a	InterviewsDepression scaleSelf-esteem scaleDelinquency acts checklist9-item Violence scaleMaterial advantages indexDispossessed questionnaire	Results showed that bereaved adolescents experienced more behavioral problems and social-psychological adjustment issues than did non-bereaved. Results also showed that adjustment behaviors lowered as adulthood approached. Other conclusions from this study showed earlier school withdrawal; a positive association between lower interest in college and lower academic achievements and lower economic situations; greater delinquency; greater fighting behavior; greater drug use; higher likelihood of school suspension; more depressive symptoms; lower self-esteem; more suicide thoughts and attempts; negative self-image of health; higher rates of mental health guidance; and parental death was much more prevalent in lower socio-economic status groups; and, finally, females displayed lower interests in getting married.

Note. USA represents the United States of America; QN represents Quantitative; QL represents Qualitative; M represents Male; F represents Female; ADOL represents Adolescents; AUS represents Australia; CAN represents Canada; SW represents Sweden; UK represents The United Kingdom; DEN represents Denmark; RW represents Rwanda; NL represents Netherlands; CY represents Cyprus; IR represents Iran; MX represents Mixed Study; DES represents Study Design; CTY represents Country; RBS represents Registered-based Study; PD represents Parental Death. Quantitative measures used; BDIS represents the Beck Depression Inventory Scale; ISSS represents the Informant Social Support Scale; DDT represents the Differential Diagnostic Technique, HTFI represents the Hollingshead Two-Factor Index; IAS represents the Imaginary Audience Scale; SEDQ represents the Social and Emotional Development Questionnaire; EPI represents the Eysenck Personality Inventory; GHQ represents the General Health Questionnaire; BIS represents the Body Image and Impulsivity; OSIQ represents the Offer Self-Image Questionnaire; ANOVA represents the Analysis of Variance; CDI represents the Children Depression Inventory; YSR represents the Achenbach Youth Self-Report; IES represents the Impact of Event Scale; TRF represents the Teacher Report Form; CBC represents the Child Behavior Checklist; DISC represents the Diagnostic Interview Schedule for Children; ETGI represents the Expanded Texas Grief Inventory; BSI represents the Brief Symptom Inventory; HSCL represents the Hopkins Symptom Checklist; MCSDS represents the Marlowe-Crowne Social Desirability Scale; NKT represents the Newman-Keuls Tests; MPC represents the Mooney Problem Checklist; DICA-R represents the Diagnostic Interview for Children and Adolescents; CDRS-R represents the Children's Depression Rating Scale-Revised; HDRS represents the Hamilton Depression Rating Scale; FHRDC represents the Family History Research Diagnostic Criteria; SQ represents the Status Questionnaire; IPPA represents the Inventory of Parent and Peer Attachment; FESE represents the Future Expectations Scale Expectations; FESDC represents the Future Expectations Scale Degree of Certainty; K-SADS-PL represents the School Age Schedule for Schizophrenia and Affective Disorders [Present and Lifetime Version]; SCID-I represents the Structured Interview for DSM–IV Axis I Disorders; SCID-II represents the Structured Interview for DSM–IV Personality Disorders; LIFE represents the Longitudinal Interval Follow-up Evaluation; A-LIFE represents the Adolescent Longitudinal Interval Follow-up Evaluation; ICC represents the Intraclass Correlation Coefficient; CGAS represents the Children’s Global Assessment Scale, GAS represents the Global Assessment Scale for adults; DSM-III-R represents the Diagnostic Statistical Manual-III-Revised; CIDI represents the Composite International Diagnostic Interview; CGAS represents the Children’s Global Assessment Scale; GAS represents the Global Assessment Scale; ICGRC represents the Inventory of Complicated Grief–Revised for Children; ADI represents the Abuse Dimensions Inventory; C-PTSD-SSI represents the Child PTSD Symptom Scale Interview; MFQ represents the Moods and Feelings Questionnaire; SCARED represents the Screen for Child Anxiety Related Emotional Disorders; SIQ represents the Suicide Ideation Questionnaire; BAI represents the Beck Anxiety Inventory; ASIQ represents the Adult Suicidal Ideation Questionnaire-JR; LEC represents the Life Events Checklist; SRRS represents the Social Readjustment Rating Scale; FACES represents the Family Adaptability Cohesion Evaluation Scale II; WAI represents the Weinberger Adjustment Inventory; SCSS represents the Survey of Children’s Social Support; MSPSS represents the Multidimensional Scale of Perceived Social Support; KC represents the Kidcope Checklist; PDS represents the Posttraumatic Diagnostic Scale; CAPS-CA represents the Child Adolescent Post-Traumatic Stress Version of the PTSD scale; AGI represents the Adolescent Grief Inventory; HIB represents the Hogan Inventory of Bereavement Children and Adolescents; DASS-21 represents the Depression; Anxiety and Stress Scales; SAA represents the School Age Assessment of Attachment; TAAI represents the Transition to Adulthood Attachment Interview; AAI represents the Adult Attachment Interview; PCBD Checklist represents the Persistent‐Complex Bereavement Disorder Checklist; HR refers to Hazard Ratio; OR refers to Odds Ratio; and CI refers to Confidence Interval.

Sources enlisted in Table 1 describes the final selected articles pertaining only to adolescent bereavement. Since this current review includes studies on parental death during adolescence only, all studies of adolescent bereavement that included other types of death, other than parental death, were excluded from this review. Mixed studies with adult/adolescent participants were also excluded.

Theme Identification

Having established the article set, the authors sought to identify quotes pertaining to adolescent grief as well as identifying impacts that grief had on their mental and physical health, their school life and their family unit. In total, 83 quotes were retained for analysis (which included a total of 135 codes). These quotes were then coded. The individual codes were then categorized into four main themes as depicted in Figure 2: (i) reactions to the death (n = 93, 57.8%), (ii) impact of death (n = 38, 23.6%), (iii) thoughts related to deceased parent (n = 20, 12.4%), and (iv) coping behaviors (n = 10, 6.2%).

Figure 1.

Flowchart of Studies Selected.

Figure 2.

Distribution of Main Themes.

Specifically, reactions to death was divided into physical (28), psychological (40), and behavioral (25). Psychological reactions were then further split into anxiety or depression (14) and everything else (26). Impact of death was also divided into impact on school (22) and impact on family (16). In the third category, thoughts related to the deceased, bond continuation (10) was separated as a distinct theme from thoughts related to the deceased (10). Finally, the most commonly cited needs category has a total of 10 codes. The details of this coding distribution are summarized in Figure 2.

Results

Literature Synthesis

The phenomenon we described in the current literature review is based on the feedback documented by bereaved adolescents to parental death. They are in order of frequency: (1) reactions to the death; (2) social impact caused by death; (3) thoughts related to deceased parent; and (4) coping behaviors.

Reactions to the Death

Behavioral

Excerpts about behavioral reactions from bereaving adolescents were predominantly negative. As per a study by Meshot and Leitner (1993), due to parental loss, adolescents experienced sleep disturbance, more irritability, anger and difficulties being with people. Moreover, a seminal study,one of the very first conducted in 1991 on this area of research, reported that in the second half of the year following the death, a few subjects experienced the onset of significant and new problems which included depression, alcohol abuse, delinquency, and threatened school failure (Harris, 1991, p. 272). More specifically regarding behavioral reactions in the youth population dealing with grief, besides feeling sad, fearful and guilty, and crying over the deceased parent, some adolescents may go as far as experiencing suicide ideation after the death of a parent (Hill et al., 2019). Similarly, Høeg et al. (2017) stated that bereaved adults who experienced death of a parent in their youth reported significantly higher substance use, behavioural disengagement, and emotional eating than non-bereaved adults). In a study conducted by Høeg et al. (2017), of the 2,390 adult participants, 574 had lost a parent between the ages of 13 and 18. The authors reported no significant difference between ages and gender for those who had experienced parental loss regarding long-term negative effects. Moreover, youth obesity was also shown to be linked to early parental death, wherein the youth is now faced with a new family structure and subjected to a new way of parenting that may potentially affect eating habits. This study showed how, for adolescents, the experience of losing a parent may negatively affect coping behaviors later on in their adult years. Furthermore, adolescent problem behaviors, crying, anger, shock, psychiatric hospitalization and more sexual risk behaviors have been described as behavioral reactions to grief in this specific target population (Harris, 1991; Meshot & Leitner, 1993; Rotheram-Borus et al., 2001).

Psychological: Other Than Anxiety and Depression

Excerpts from psychological reactions (other than anxiety and depression) were all negative, and detailed an increase of various psychological problems. For example, Raphael et al. (1990) identified increased neuroticism; Karakartal (2012) found increased levels of guilt and extreme fear; Stikkelbroek et al. (2012) mention a prevalence of dysthymia and bipolar episodes as well as incidences of phobia and panic; Hill et al. (2019) identifies reported higher levels of suicide ideation; and extreme cases found the need for psychiatric hospitalization (Harris, 1991).

Psychological: Anxiety and Depression

Anxiety and depression were the most commonly found reactions amongst bereaving adolescents. A study conducted by R. E. Gray (1987) suggests that depression was significantly found as a reaction to the loss of a parent and that “individuals categorized as having a passive/dependant personality were particularly prone to depression if they received low support” (p. 517). In addition, R. E. Gray (1987) also reported higher levels of depression in adolescents who described having poor past relationships with the deceased parent, most probably due to unstable family structures at the time of the death. Identically, Stikkelbroek et al. (2012) reported that major depressive disorder as well as anxiety disorder were amongst the most prevalent mental disorders following parental loss. In addition, Servaty and Hayslip (2001) suggested that depression and anxiety were prevalent due to parental death.

Physical

Excerpts related to physical reactions due to parental loss range from sexual activity, severe problems such as sleep disturbance, and irritability (Meshot & Leitner, 1993; Raphael et al., 1990; Raza et al., 2008). Interestingly, sexual activities ranged from not being sexually active to being more sexually active than usual (Raphael et al., 1990). Insomnia was also detected as a physical reaction but more so in women than in men (Meshot & Leitner, 1993). This disturbance in sleep was also found in a study conducted by Harris (1991), where the first six months after the death of a parent were greatly affected by disturbances in sleep.

Social Impact Caused by Death

School

Excerpts about impacts on school were predominantly (all but one) negative. The negative issues included decreased perception of performance, decreased performance, delinquency, failure to be promoted, decreased ability to focus, adjustment issues at school and when moving on to university. The positive excerpt was about increased energy and focus as a coping strategy that lead to increased performance. Specific coding for this section includes a range of behaviors. Codes included both general behaviors as problematic as well as specific behavior issues. An example of the decreased performance code that also includes decreased ability to focus is Karakartal (2012), reporting severe concentration problems and decline in school performance. Other researchers reported similar effects on school environment, including subjects who were threatened with failure to be promoted (Harris, 1991, p. 272), and college adjustment (Raza et al., 2008, p. 18). The only positive remark was from Apelian and Nesteruk (2017), where they report one of the main coping strategies as “the participants were working hard in school” as opposed to a study conducted by R. E. Gray (1987), in which school grades were negatively affected by parental death in those aged 15 years or younger, and were also lower when compared to older adolescents aged 15 and older.

Family

Excerpts about impacts on the family unit have shown the presence of both alcohol-related and psychological problems in their families (Raphael et al., 1990). Surviving parents or guardians were shown to play powerful roles in their child’s life, as stated by Brewer and Sparkes (2011), although the relationship the participants had with their dead parents appeared to be just as important and was discussed by them in great depth. Similarly, a study by Patterson and Rangganaddhan (2010) demonstrated that adolescents who had lost a parent ended up replacing the dead parent with household responsibility to help the surviving parent, a reaction known in pedo-psychiatry and psychology as child parentification (Boszormenyi-Nagy, 2013; Hardman, 2019; Haxhe, 2013; F. B. Simon et al., 1985).The parentification is a relational process internal to family life, which leads the adolescent to take on greater responsibilities than his/her age and maturity typically does, and in a specific socio-cultural context leading them to assume the role of the parent for the widow parent. This coping strategy can have serious consequences for the adolescent’s development and their future relationships. In general, adolescents felt that a stronger support system was necessary for them to deal with this experience, such as feeling that the “surviving parent was not a supportive resource to help them cope with the death” (Apelian & Nesteruk, 2017, p. 90). Furthermore, Harris (1991) reported that adolescents spent less time at home and more time with peers, frequently relying on a best or special friend.

Thoughts Related to the Deceased Parent

Bond Continuation

Excerpts about bond continuation in multiple studies describe how the deceased parent, although physically gone, still remains in the minds and hearts of the adolescent. For example, Hansen et al. (2016) report how inner guides, encounters, or mementos were reported as continued bonds by the grieving adolescents . For example, “Adolescents described encounters as unexpected experiences with a deceased parent and perceived them as positive or negative” (p. 361). Furthermore, in the same study, “keeping special items (mementos) as a way to connect with a deceased parent” (p. 361) was mentioned. Similarly, Meshot and Leitner (1993) described how this continued bond with the deceased was due to the magnitude of loss that was experienced by the adolescent,who had felt a “strong presence of the deceased in dreams and in other people” (p.287).

These results confirm a previous study by Silverman and Silverman (Silverman & Silverman, 1979) reporting that children who were able to develop a way of keeping a relationship with their lost parent in their life were also better able to accept the reality of death. Finally, certain teenagers continued their bond with their dead parents by displaying little desire to relinquish the lost parent (Harris, 1991).

Thoughts Directly Related to the Deceased

Excerpts from various studies showed how bereaved adolescents continued to keep the deceased parent in their mind through certain specific thoughts, such as identifying with the deceased parent by, for example, “acquiring the habits and interests of the deceased as well as feeling that the deceased is still with them” (Meshot & Leitner, 1993, p. 287). Additionally, a study conducted by Dehlin and Reg (2009) reported other types of thoughts directly related to the deceased, such as the bereaved teenager wishing strongly for the parent to be brought back to life, knowing that this was not the reality. Similarly, in another study by Harris (1991), it was documented how one adolescent enjoyed speaking about their deceased parent while another adolescent reported feeling uneasy about not having had the proper closure with their parent before their passing.

Coping Strategies

Excerpts directly related to specific needs of the adolescent population following parental death reflected the importance of friends and peers for how this population desires to be supported during their grief. For example, Brewer and Sparkes (2011) found that social support and friendships were instrumental in cultivating happiness after the death of a parent. Other important resources included either immediate family members or extended relatives (Apelian & Nesteruk, 2017) as well as school-based professional support (Harris, 1991). Advantages of social support for the bereaved adolescent were reported as coming from either family, such as the surviving parent or siblings, and friends (Apelian & Nesteruk, 2017). It was declared by all subjects in this study that emotional support, working hard in school and socializing with friends was crucial in how they all dealt with parental death. In fact, one participant stated that she had a lot of friends at the time she experienced parental loss and it was “really helpful and continues to be helpful even as life has gone” (p. 91). Although these coping mechanisms included family and friends, some participants also felt the need to self-isolate as they chose to be alone to grieve, for example, as they listened to music.

Despite the negative impacts of parental loss on adolescents, the following declarations show how losing a parent can have positive effects for youth as well, as one participant stated that “If you’re alone for a couple of weeks and you’re feeling down, then it builds character in my opinion” (Apelian & Nesteruk, 2017). For these participants, speaking as an adult about the loss of their parent was still difficult. However, they reported that, in general, the loss made them “stronger, helped them gain maturity, and fostered a different perspective on life” (p. 92). Adulthood arrived more quickly for most of the bereaved adolescents as they reported how losing a parent changed them in both maturity and personal growth. Suffering seemed to be taken in a positive light, as one adolescent mentions that, “suffering makes you learn a lot about life, about yourself, about others, about everything — it makes you grow” (p. 92).

Gender Differences

Research in this area of study has shown that females have a tendency to grieve more on an emotional basis than do males, as “women had a higher degree of mourning accompanied by crying and the feeling of needing to cry than men” (Meshot & Leitner, 1993, p. 287). This study reported gender differences in the adolescent population in the way they grieved. Participants in this study showed that women (a) declared having grieved longer on the death than did men, and (2) reported higher levels of unresolved grief than men. Similarly, a study conducted by Raphael et al. (1990) found that females reported more general health problems and had higher neuroticism and also had a more negative perception of their school performance. In research, female adolescents partook in a study to express their perspectives of grief and coping due to parental loss (Cait, 2005). Although women tended to describe the death experience as an “evolving process”, grieving was nonetheless a process that “is not encapsulated [and] neatly packaged and contained in a person’s life” (p. 92). Changes in their life included both (a) having a different identity within the new household structure, with an increased responsibility level towards the remaining parent, and (b) developing a newly formed relationship with the remaining parent. This new relationship is labelled by the author as “situational matrimony” (p. 92), resulting from the magnification of the relationship with the remaining parent.

Similarly the young women expressed changes in the family dynamics, such as becoming caregivers and having to take care of the remaining parent in similar ways as would the deceased parent (Cait, 2008). Perceptions of family cohesion were significantly different between males and females in a study specifically assessing gender conducted by Birgisdóttir et al. (2019). When compared to non-bereaved youth, only maternally bereaved female participants had poor family cohesion perceptions that lasted into adulthood, as opposed to males, who did not. This study also showed that female adolescents’ well-being appears to be linked to the type of family relationship; thus female, compared to male bereaved adolescents, experience more emotional distress as a reaction to poor family cohesion. Finally, this study also reported more internalization by females as well as higher levels of vulnerability than their male counterparts. In the same study, females were also shown to have more responsibility within this new family structure than males had.

A study conducted by Lawrence et al. (2006) reported that coping styles differed between males and females, but (a) only in avoidant coping styles, (b) in females, and (c) due to depression. While this finding related to gender differences, the authors did report no significant differences between males and female across coping style. Similar findings were reported in a study conducted on various types loss and grief experienced by orphaned children in Kenya, with absence of gender difference on adjustment to loss and grief in orphan secondary school students (Owaa et al., 2015, p. 493). In general, boys kept more to themselves while girls spoke more about their grief than did boys, demonstrating gender differences when adjusting to grief and loss. To support this point, two other studies on gender differences have reported that females showed higher levels of emotional suffering than males but reported fewer behavior problems than did males (Rotheram-Borus et al., 2001; Servaty & Hayslip, 2001). Martin et al. (2000) suggest that these gender differences may be based on the different ways boys and girls are socialized. More research is needed in this area to support both male and female parentally bereaved adolescents. In a study conducted by Feigelman et al. (2017), similar reactions to parental death were reported for both males and females. More specifically, results showed shared reactions for both males and females, such as greater substance use, greater delinquency, as well as fighting behavior and running away from home. In terms of depression, results showed that depression was seen more commonly in bereaved females than in males. Another interesting result showed that where bereaved males tended to delay marriage, females were less likely to even consider it.

Discussion and Conclusion

The death of a loved one can affect many aspects of one’s life, eliciting certain reactions defined as grief. The range includes negative impacts on physical, psychological, and behavioral states as well as negative impacts on family and school life. The main symptoms reported include the development of mood disorders and increased suicidal ideations, anxiety, insomnia, addiction, as well as an increased risk of mental disorders even after 19 years old (Asgari & Naghavi, 2020; Birgisdóttir et al., 2019; Hill et al., 2019; Stikkelbroek et al., 2016) or risk of cardiovascular diseases later in life (Hollingshaus & Smith, 2015). In addition, adolescent grief may affect several aspects of their social life, more specifically in school performance and relationships with peers. In a study conducted by Karakartal (2012) it was found that some of the participants saw a decrease in their success at school, got lower grades, participated in courses less and were less interested in social activities. Moreover, experiencing the death of a parent during adolescence can also include lower family cohesion, lower self-esteem, and higher hopelessness (Brent et al., 2012).

Strikingly, there was one single instance of positive outcomes having been reported, that by Apelian and Nesteruk’s (2017) in a study on increased academic focus and performance. This data showed an increase in resilience in a sub-group of adolescents, as the participants in this study described loss as acquiring personal growth as well as resilience. One teen stated that “suffering makes you learn a lot about life, about yourself, about others, about everything — it makes you grow” (p. 92). The increase in resilience after the loss of a parent was also reported by (Tyson-Rawson, 1996), pointing out an acceleration of the maturity process, independence, autonomy and a new direction of life choices. However, more research is needed to better understand the different responses in the adolescent populations regarding the impact of parental death during adolescence across a broad range of measures.

The risk of developing depression in adolescence after the parent’s death confirms previous studies carried out in children with regards to being at a higher risk for depression if parental loss is experienced in childhood, due to developmental immaturity and insufficiently developed coping capacities (Osterweis et al., 1984). Similarly, in a study conducted by Gobbi et al. (2015), in adolescents who experienced the loss of their father due to death or divorce, an increase in depression symptomatology was found 4–6 months after the separation. Similarly, the risk of depressive symptoms for bereaved adolescents from 12–15 yo was found to be twice as high as that of children from 8–11yo, with girls at twice the risk of boys (Gersten et al., 1991). Interestingly, a study in animals conducted by Bambico et al. (2015) also confirmed the neurobiological consequences of parental loss during neurodevelopment, showing that the absence of the father, in monogamous biparental species, increases the risk for substance abuse and aggressive behavior, paralleled by a change in prefrontal cortex neurodevelopment (Bambico et al., 2015).

Furthermore, the large range of reactions and responses observed in adolescents who have experienced parental loss demonstrates the uniqueness of the human grief experience and how different these experiences may be. This provides stark evidence of the affirmation by Humphrey (Humphrey, 2009) for whom “the natural extension of appreciating the uniqueness of each person’s experience of loss and grief and her or his particular manner of adapting to loss is the importance of tailoring counseling strategies to client needs”. If the experience of loss and grief is unique, then counseling interventions that address those experiences must prioritize that uniqueness.

Given the heterogeneous responses of adolescents to grieving, it is not possible to apply general grieving processes to them. Indeed, the psychological complexity of adolescent responses, the different psychological elaboration of the loss, combined with the importance of peers and the intensity of emotions, make this age unique when faced with parental loss and mourning.

These conclusions create a clear mandate about the importance of developing deeper understanding of the adolescent bereavement process. Moreover, Worden (1996) expresses the difficulties that arise when two important life adjustments (grief and adolescence) occur simultaneously , thus creating conflict with both tasks of grief and that of adolescence. It is therefore both imperative and crucial that clinicians and experts in this field find ways to support adolescents during such a delicate time (Brewer & Sparkes, 2011). Specifically, since recent research clearly documents the range of negative reactions and impacts, future research should shift focus to analyzing treatment strategies that can effectively intervene with a population that has specific neuropsychosocial features. Finally, because peers and school are known to play such an important role in adolescent lives (Bean et al., 2019; Brown & Larson, 2009; Kiesner et al., 2004; Ryan, 2000), particular attention should be paid to interventions that can happen within a school setting or one that involves peers. Even if at the beginning of the mourning process the adolescents may feel a distance and a rift from non-orphaned peers, and a separation from the life before and after the death, friendship can serve as an important part of the mourning process supporting the resolution of the bereavement (Tyson-Rawson, 1996).

The role played by peers and school seems indeed more important than family or other types of support groups for the adolescent, suggesting that the school environment could become the main support group for adolescents in bereavement. However, more studies are necessary to better understand the role played by the school and peers versus psychotherapy interventions in adolescent bereavement. Similarly, the studies here presented mainly describe the final mental outcome, but the individual trajectories of adolescents and the response from their environment to the loss of parents merit further research.

The current review omits discussing this psychotherapeutic approach with children as this subject goes beyond the scope of this review. However, it is important to note that, in the case of complicated grief, these therapies focus on loss processing and the restoration of a life without the deceased, using cognitive behavioral therapy, interpersonal therapy, and motivational interviewing ( Simon, 2013). Finally, complicated grief therapy with adolescents appears to be an effective method when the “treatment of complicated grief involves removing the impediments to successful resolution of the grieving process” (Wetherell, 2012, p. 160). Data on bereaved adolescents, complicated grief and other therapeutic approaches merit further research as this area of research is limited (Salloum et al., 2019).