Introduction

For all bereaved individuals, life is forever changed from the moment they learn of their loved one’s death. Irrespective of the circumstances, bereavement is a universal phenomenon best conceptualized as adjustment to a death and the subsequent absence of a significant and often cherished person. It is a complex, multidimensional process involving the physical, psychological, sociological, and spiritual domains of the human experience (Sanders, 1999) where the strength of the attachment bond between the deceased and the bereaved is believed to be central (Bowlby, 1980). Coping following a significant loss is influenced by many factors, including the nature of the death, the relationship with the deceased, and the social and cultural context in which bereavement is experienced (Malkinson, 2007; Stroebe, Schut & Stroebe, 2007).

The grief experienced by parents following the death of a young, dependent child presents its own specific difficulties. Just as the relationship between a parent and child is uniquely strong, so too is their grief. This bereavement experience is generally regarded to be severe and long, characterized by yearning, extreme sadness, and a sense of isolation from others (Dyregrov & Dyregrov, 1999; Goodenough, Drew, Higgins & Trethewie, 2004; Kreicbergs, Lannen, Onelov, & Wolfe, 2007; Rando, 1986), features often noted in those suffering from Prolonged Grief Disorder (Prigerson et al., 2009). The death of a child at any age is a devastating life event that occurs “off-time” (Neugarten, 1979) challenging one’s beliefs about the world and its natural order (Malkinson, 2007). Current diagnostic formulations about normal and complicated grief reactions are largely based upon research whose subjects have experienced spousal loss and as such, may not be entirely generalizable to the experience of bereaved parents (Bonanno et al., 2002; Maciejewski, Zhang, Block & Prigerson, 2007; Shear, 2015).

Normal bereavement typically refers to the experience of the majority of individuals who cope with their losses without requiring professional intervention (Morris & Block, 2012). In the initial months following a death, intense feelings of sadness, yearning for the deceased, anxiety about the future, and feelings of emptiness are common, as is replaying the events of their loved one’s last days. These symptoms of acute grief typically diminish in intensity over time, as the loss becomes integrated into the bereaved person’s identity and life (Morris & Block, 2012).

While grief has been popularly conceptualized as a stage model through Kübler-Ross’s work with dying patients (Kübler-Ross, 1969), normal grief is now considered to be a highly individualized process without distinct stages or phases. Waves of intensified emotion or ‘pangs’ of grief characterized by yearning are also considered a core element (Bowlby & Parkes, 1970). The Diagnostic and Statistical Manual of Mental Disorders states that the “dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief” (American Psychiatric Association, 2013, p. 161). Bereavement research has tried to understand the trajectory and timing of normal grief responses (Bonnano et al., 2002; Maciejewski et al., 2007), how individuals cope with bereavement (Stroebe & Schut, 1999) and the ways in which bereaved individuals find meaning and adapt to the death of their loved one (Lichtenthal, Neimeyer, Currier, Roberts, & Jordan, 2013; Neimeyer, 2000).

From a psychological perspective, attachment is believed to play a significant role in the bereavement experience. Defined as the enduring emotional bond that humans feel toward some other differentiated and preferred individual (Bowlby, 1980), its centrality in bereavement was captured by Bowlby, whose work also emphasized attachment as the core psychological task of infancy, in which both the infant and the parent have a life-defining role. He noted that in bereavement, attachment bonds endure, despite the tendency to assume that a person can and should get over the death of a loved one quickly and completely (Bowlby, 1969).

Distinguishing normal bereavement from complicated grief reactions has been the focus of much research over the two past decades (Lichtenthal, Cruess, & Prigerson, 2004; Maciejewski et al., 2007; Prigerson et al., 2009). Cultural norms of mourning can be hard to distinguish from individual emotional responses, and different grief responses may be considered ‘normal’ for different kinds of losses or in different cultures. Attempts to define outliers who experience severe grief reactions, requires understanding normal variation in grief responses and their measurement. Even when the importance of culture as a mediator of expression is recognized, strong evidence for a core experience of grief can be seen from cross-cultural research using grief assessment tools, in particular the Prolonged Grief Disorder 13 item scale, PG-13 (He et al., 2014). While emotional expression and the griever role may be culturally bound, research has found conserved responses after different kinds of death and in different ages in the bereaved around the world (Coelho, Silva & Barbosa, 2017; Delalibera, Coelho & Barbosa, 2011; Djelantik, Smid, Kleber, & Boelen, 2017; Field et al., 2014; Goodenough et al., 2004; Heeke, Stammel, & Knaevelsrud, 2015; Kristensen, Dyregrov, Dyregrov & Heir, 2016; Tsai et al., 2016; Xiu et al., 2016; Xu, Fu, He, Schoebi & Wang, 2015; Xu, Herrman, Bentley, Tsutsumi, & Fisher, 2014).

Understanding this core set of grief-related symptoms also elucidates criteria to recognize outliers and symptoms that comprise complicated or prolonged grief responses. Health professionals are responsible for distinguishing ‘pathological’ bereavement reactions from healthy but distressed coping. Research has endeavored to understand the disabling form of grief in which maladaptive thoughts, feelings, and behaviors interrupt the natural adaptive process, resulting in the intensification and prolongation of acute grief symptoms (Prigerson et al., 2009; Shear, 2015; Shear et al., 2016; Stroebe et al., 2007; Zisook, Chentsova-Dutton, & Shuchter, 1998). Complicated or prolonged grief affects 2–3% of the general population and approximately 10% of bereaved individuals (Lundorff, Holmgren, Zachariae, Farver-Vestergaard, & O’Connor 2017), with a prevalence of 10–20% after the death of a romantic partner (He et al., 2014; Kersting, Brahler, Glaesmer, & Wagner, 2011; Prigerson et al., 2009; Shear, 2015; Shear et al., 2016). For bereaved parents, the rates are even higher. Kersting et al. (2011), for example, found a prevalence of 23.6% in a population-based sample including bereaved parents and recently, Goldstein et al. (2018) reported a prevalence of prolonged grief in 50% of mothers whose babies died suddenly and unexpectedly from SIDS.

Prolonged Grief Disorder (PGD), complicated grief, and Persistent Complex Bereavement Disorder are terms to describe the debilitating set of symptoms identified in those with a problematic adjustment to a loss, marked by intrusive yearning and a defined number of cognitive, emotional, and behavioral symptoms (Boelen & Prigerson, 2007; Maciejewski, Maercker, Boelen, & Prigerson, 2016). PGD will be included in ICD-11 as a disorder specifically associated with stress (http://ICD.who.int) and Persistent Complex Bereavement Disorder exists as a condition of further study in the DSM-5 (American Psychiatric Association, 2013). These diagnostic categories characterize a state of intense yearning and sadness, typically accompanied by persistent thoughts or memories of the deceased and an inability to accept the reality of the loss (Prigerson et al., 2009). Rumination is common, and individuals with complicated or prolonged grief often avoid situations that remind them of the loss and also withdraw from family and friends (Shear, 2015).

Pathological bereavement has been shown to be a distinguishable syndrome by confirmatory factor analysis (Boelen, van de Schoot, van den Hout, de Keijser & van den Bout, 2010), distinct from grief-related depression (Prigerson, Frank et al., 1995), anxiety (Prigerson et al., 1996; Prigerson, Frank et al., 1995), major depressive disorder (Prigerson et al., 1996; Prigerson, Frank et al., 1995), or Post-Traumatic Stress Disorder (PTSD) (Prigerson et al., 2009). Yearning or intense searching behavior for an attachment figure is a primary symptom in prolonged grief but is not usually present in major depression or PTSD (Shear, 2015). Guilt is common in both prolonged grief and major depression. However, with prolonged grief the focus is usually associated with regrets or ambivalence related to the deceased or their care, whereas in major depression, the source relates to feelings of worthlessness (Shear, 2015). In PTSD, guilt and perseveration may be present but are usually associated with the traumatic event, whereas in prolonged grief intrusive thoughts are focused on memories of the deceased (Shear, 2015).

A number of risk factors for prolonged grief have been identified (Bonanno et al., 2002; Currier, Holland, & Neimeyer, 2006; Goodenough et al., 2004; Keesee, Currier, & Neimeyer, 2008; Kersting et al., 2011; Klingspon, Holland, Neimeyer, & Lichtenthal, 2015; Kreicbergs et al., 2007; Stroebe et al., 2007; Vanderwerker, Jacobs, Parkes, & Prigerson, 2006; Wijngaards-de Meij et al., 2008; Wright, Keating, Balboni, Matulonis, & Block, 2010; Zisook & Shuchter, 1991; Zisook et al., 1998). These risk factors emerged from research examining pre-existing vulnerabilities in the bereaved or the nature of the death itself (Parkes, 1998) and are listed in Table 1. While these risk factors are not all specific to the death of a child, several are weighted toward aspects of loss that are especially relevant to the experience of young parents, including the death of a younger child (Wijngaards-de Meij et al., 2005), near kinship, dependent relationship (Li, Laursen, Precht, Olsen, & Mortensen, 2005), and being a mother (Cleiren, Diekstra, Kerkhof, & van der Wal, 1994; Goodenough et al., 2004; Li, Precht, Mortensen, & Olsen, 2003).

Table 1 Risk factors for complicated and prolonged grief
Full size table

In the United States today, the death of a child is a relatively uncommon event, where approximately 44,000 children younger than 19 years die each year with over 50% of that mortality occurring in the first year of life according to the Centers for Disease Control and Prevention (http://www.wonder.cdc.gov). As a result, bereaved parents of dependent children are in the minority, belonging to a small and often isolated group of individuals. Not only are these bereaved parents relatively young and generally unacquainted with significant loss, but also well-developed bereavement services and supports from health professionals and the wider community vary greatly and are not always readily available (Lichtenthal et al., 2015; Morris & Block, 2015). In this context, important questions exist about what is normal grief, as opposed to ‘pathological’ grief, following the death of a child. The fact that young adults of childbearing age are a demographic that historically underutilizes primary healthcare also limits medical awareness of this problem and the potential for early intervention (Fortuna, Robbins, & Halterman, 2009). Young parents are more likely to attend to the medical care of their other children than to have significant primary medical relationships themselves, with the implication that many struggle to adjust to the loss without medical or mental health services. Any assessment of the prevalence of their needs occurring in medical settings is, at the very least, unreliable.

In this paper, we present a review of empiric research on parental grief resulting from the death of a younger, typically dependent child in the pediatric range, and its lasting impact on parents. We summarize a more systematic review of the literature of relevant publications from 1995 to 2017, examining complicated or prolonged grief in bereaved parents. We consider whether unique aspects of parental grief are sufficient to conclude that it is a distinct subtype of grief, deserving of special attention in future research and diagnostic formulations. Finally, we discuss future directions for research and practice highlighting a role for psychologists in medical settings in raising awareness about the unique needs of bereaved parents and how we might better support them during their bereavement.

Methods

To consider research specifically examining the grief of parents following the death of a child within the pediatric age range, this review addressed the key hypothesis that there is sufficient evidence to conclude that parental grief is a distinct subtype of grief, deserving of attention in future research and diagnostic formulations.

We reviewed the literature addressing grief outcomes from 1995 to 2017, searching Pubmed, PsycINFO, and Web of Science using the terms: ‘parental complicated grief’, ‘parental traumatic grief’ and ‘parent Prolonged Grief Disorder’. We selected this time frame as it coincides with the beginning of research into pathological grief reactions, including the development of the Inventory of Complicated Grief (ICG) (Prigerson, Maciejewski et al., 1995), the first diagnostic tool specific to pathological grief.

Only studies that used a validated grief measure such as the ICG or PG-13 were included because they provide objective criteria and have been used in research leading to the development of the diagnostic criteria for pathological bereavement proposed for DSM-5 and ICD-11 (Prigerson et al., 2009; Luciano, 2015; Maercker et al., 2013). Our initial search produced a total of 289 unique abstracts of which, 42 met our inclusion criteria. Of these 42 studies, 35 were cross-sectional studies and 7 were longitudinal. Table 2 summarizes these studies, categorized in chronological order according to the type of death: cancer-related deaths (4), sudden deaths (16), and mixed-loss studies (22), where various causes of death were combined in the same study. We chose to categorize the studies according to type of death, a convention commonly seen in the literature, to enable the reader to more easily review the findings from similar causes of death.

Table 2 Summary of parental grief studies categorized according to type of death
Full size table

Results

From the 42 studies that were identified, we found great variation in sample composition, causes of death, inclusion of comparison groups, the use of convenience samples, psychometric measures used, and post-interval follow-up, making comparisons difficult and severely limiting the basis for a more formal meta-analysis. Aligning with the risk factors from the broader bereavement literature listed in Table 1, researchers found increased levels of unresolved, complicated, or prolonged grief in parents of children dying from virtually any cause. These rates vary depending on the cause of death, ranging from 10% following an expected death from cancer (McCarthy et al., 2010), to 94% following traumatic death as a result of the ferry accident in South Korea where 261 high school students and teachers died (Huh, Huh, Lee & Chae, 2017).

Poorer outcomes in bereaved parents were evident on the following basis:

Kinship

Kinship is a risk factor for worsened grief, and bereaved parents experience higher levels of grief intensity than either adults who have lost spouses, parents, or other loved ones (He et al., 2014; Middleton, Raphael, Burnett, & Martinek, 1998; van Denderen, de Keijser, Huisman, & Boelen, 2016). Twelve studies made direct comparisons based on kinship, comparing bereaved parents to other bereaved individuals or mothers to fathers. Middleton et al. (1998) found that bereaved parents scored significantly higher on the Core Bereavement Items questionnaire than bereaved spouses, who in turn scored higher than adult children who had lost parents. Mothers, in particular, seem to have a higher risk for more severe grief compared to fathers (Büchi et al., 2007; Goodenough et al., 2004; Keesee et al., 2008; Meert et al., 2010; Michon, Balkou, Hivon, & Cyr, 2003; Tseng, Cheng, Chen, Yang, & Cheng, 2017), and parents whose only child died seem to fare worse (Büchi et al., 2007; McSpedden, Mullan, Sharpe, Breen, & Lobb, 2017; Meert et al., 2011; Tseng et al., 2017; Wijngaards-de Meij et al., 2005; Xu et al., 2014). For bereaved individuals with complicated grief, bereaved parents reported significantly more yearning, preoccupation with the deceased, anger, and bitterness than other bereaved individuals (Zetumer et al., 2015). Similarly, Baddeley et al. (2015) found that following a violent death, bereaved parents were significantly more likely to experience daily thoughts of reunion with their child (43.1%) and remorse (43.5%) than other relatives or friends (24.7% and 18.7% respectively), even though in this study there were no significant differences between the groups on measures of complicated grief, depression, and PTSD.

Sudden Death

Parents whose children died suddenly and unexpectedly, whether from extreme prematurity, SIDS, accidents, homicide, or suicide, have been shown to have an especially high burden of grief-related symptoms (Büchi et al., 2007; Dyregrov et al., 2003; Keesee et al., 2008; Michon et al., 2003; van Denderen et al., 2016). Dyregrov, Nordanger, & Dyregrov (2003) found that parents bereaved following accidents or suicide reported greater subjective distress than those whose children died from SIDS, while self-isolation was the best predictor of psychosocial distress in all three groups. Traumatic deaths following suicide (Mitchell, Kim, Prigerson & Mortimer-Stephens, 2004), homicide (van Denderen et al., 2016), a stampede in Cambodia (Field et al., 2014), the 2011 terror attack in Norway (Kristensen et al., 2016) and the ferry accident in South Korea (Huh et al., 2017) also produced high levels of PGD in parents and in some studies, other close relatives. Kristensen et al. (2016), for example, found that bereaved parents (and siblings) who were in contact with the child during the Norwegian attack and who had high levels of media exposure in the month after had significantly higher levels of PGD than those who didn’t.

Location of Death/End-of-Life Experience

Hospital deaths were associated with severe grief. Parents whose children died in hospital from cancer have been found to experience more grief symptoms than parents whose children died at home (Drew, Goodenough, Maurice, Foreman, & Willis, 2005; Goodenough et al., 2004). Drew et al. (2005) found that parents whose children received a Stem Cell Transplant (SCT) and who died in the hospital had significantly higher rates of traumatic grief than those parents whose children had not received a SCT. Bereaved fathers whose children died in the hospital from cancer had significantly higher levels of depression, anxiety, and stress compared to fathers whose children died at home (Goodenough et al., 2004). However, when a child died of a sudden death in the home, parents reported higher grief intensity than when they died in a hospital setting (Michon et al., 2003). Preparedness and the quality of the end-of-life experience were also found to influence grief. Parents who reported feeling less prepared for their child’s death or perceived the quality of their child’s end-of-life experience to be poor had higher levels of complicated or traumatic grief (McCarthy et al., 2010; van der Geest et al., 2014). Conversely, parents who felt their needs were better met at the end of their child’s life had lower complicated grief scores (Meert et al., 2012), and parents who were able to say ‘goodbye’ to their child (Wijngaards-de Meij et al., 2008) or attend rituals following perinatal loss had lower grief scores (Tseng et al., 2017).

Economic Hardship

For parents of children with cancer, McCarthy et al. (2010) found that economic hardship and a shorter time since the child’s death predicted higher complicated grief scores. Similarly, Xiu et al. (2016) reported that for Chinese parents, a poorer financial situation predicted PGD as well as poorer health, lower satisfaction with life, and a more cynical worldview. Following the South Korean ferry accident, Huh et al. (2017) found that parents reported a decrease in their mean income and 32% were unemployed.

Attachment Style

The attachment style of the parent was found to impact grief intensity. Insecure attachment styles predicted more severe grief and depression following the death of a child from a variety of causes (Wijingaards-de Meij et al., 2007), and attachment avoidance and attachment anxiety predicted higher levels of complicated grief following the sudden death of a child (Meert et al., 2010).

Sense-Making and Benefit-Finding

Bereaved parents who were unable to make sense of or find benefit in their child’s death reported worse grief outcomes (Bogensperger & Lueger-Schuster, 2014; Keesee et al., 2008; Lichtenthal, Currier, Neimeyer, & Keesee, 2010; Lichtenthal et al., 2013). Lichtenthal et al. (2010) studied patterns of meaning-making in parents whose children died from either violent or non-violent deaths. They found that 45% of bereaved parents reported being unable to make sense of their loss and 21% found no benefit to their experience. In relation to violent deaths, 53% of bereaved parents reported being unable to make sense of their loss compared to 32% following non-violent deaths (Lichtenthal et al., 2013). Zetumer et al. (2015) found that bereaved parents with complicated grief reported more anger, bitterness, shock, and disbelief compared to other bereaved individuals with complicated grief. They also reported more indirect suicidal behavior and greater beliefs that they may engage in suicidal behavior in the future than other bereaved individuals with complicated grief.

Several studies focused on factors associated with coping and post-traumatic growth following the death of a child. Büchi et al. (2007) found that mothers demonstrated greater post-traumatic growth than fathers after the death of an extremely pre-term infant. In another study, mothers who were more optimistic and coped in an active way, for example, by planning and taking direct action, experienced less intense grief (Riley, LaMontagne, Hepworth, & Murphy, 2007). Similarly, mothers who utilized avoidance coping strategies, such as distraction through social interactions or activities, fared better than mothers who used emotion based coping involving concentration on the strong emotions accompanying their grief (Anderson, Marwit, Vandenberg, & Chibnall, 2005). Making sense of the death in some way has been found to predict post-traumatic growth especially for unexpected deaths (Bogensperger & Lueger-Schuster, 2014), and parents with increased spirituality or those who made sense of the death based on their religious beliefs had lower grief and depression scores (Hawthorne, Youngblut, & Brooten, 2016; Lichtenthal et al., 2010). Finally, maintaining a bond with the deceased child appears to be protective (Ronen et al., 2009; Scholtes & Browne, 2015).

Discussion

This aim of this review was to examine whether there is sufficient evidence to conclude that parental grief is a distinct subtype of grief, deserving of attention in future research and diagnostic formulations. We reviewed 42 studies that used a validated grief measure of complicated or prolonged grief in bereaved parents and identified several themes that indicate poorer outcomes. These were kinship, sudden death, location of death and end-of-life experience, economic hardship, attachment style, and a parent’s ability to make sense of their child’s death. We believe that the findings from this review support our hypothesis that a conceptual and empirical basis does exist to conclude that the grief of parents for their young children is worthy of attention, separate from research that has typically focused on spousal loss.

A substantial body of literature exists, which demonstrates that bereavement following the death of a child is accompanied by a significant increase in mortality, and physical and mental health problems in bereaved parents, including increased depression and first rate of psychiatric hospitalizations (Bolton et al., 2014; Christiansen, Olff, & Elklit, 2014; Dyregrov et al., 2003; Goodenough et al., 2004; Lannen, Wolfe, Prigerson, Onelov & Kreicbergs, 2008; Li et al., 2003; Li et al., 2005; Ljung et al., 2014; Ljungman, Hovén, Ljungman, Cernvall, & Essen, 2015; Rogers, Floyd, Seltzer, Greenberg, & Hong, 2008; Youngblut, Brooten, Cantwell, del Moral, & Totapally, 2013; Wijngaards-de Meij et al., 2008; Wilcox, Mittendorfer-Rutz, Kjeldgard, Alexanderson, & Runeson, 2015). Family and marital life is also disrupted (Bolton et al., 2014; Dussel et al., 2011; Li et al., 2005; Rogers et al., 2008). Given that young adults often underutilize health care (Fortuna et al., 2009), identifying those bereaved parents most at risk presents a challenge for our health system.

Against this background, this review found estimates of complicated and prolonged grief ranging from 10% (McCarthy et al., 2010) to 94% (Huh et al., 2017) in bereaved parents following different types of death, while complicated grief occurs in approximately 10% of bereaved individuals as reported in a recent meta-analysis (Lundorff et al., 2017). Perhaps more revealing is the extent that bereaved parents endorsed feelings of intense yearning for their deceased child (Baddeley et al., 2015; Zetumer et al., 2015), which is consistent with our recent research reporting that 68.1% of bereaved mothers from SIDS endorsed yearning for their child (Goldstein et al., 2018). It seems reasonable to conclude therefore that yearning is more normative in bereaved parents than other bereaved individuals, reflecting the significance of attachment theory and the role of parent as nurturer and protector (Bowlby, 1980).

We believe these findings have important implications for how we conceptualize normal and ‘pathological’ grief reactions in bereaved parents and raise two important questions. First, given the importance of the attachment bond between a parent and child, do the same expectations for bereavement outcomes extracted from research largely based on spousal loss apply when the death occurs during a time of high dependency and enriched attachment? Second, given the uniqueness of the loss of a young child, can we assume that this loss resolves or becomes integrated in the parents’ lives in the same way as other types of losses?

The great variation found in these studies makes comparisons and drawing specific conclusions about the impact on parents following the death of a child very difficult, and competing diagnostic formulations is a major limitation. To answer these questions, future research would benefit from consensus on diagnostic categories and terms, the use of the same validated measures and research guidelines about sample composition, the causes of death studied and post-loss intervals specific to child loss. It must also be noted that within the literature ‘parental’ disproportionately has meant ‘maternal’ (MacDonald, Chilibeck, Affleck, & Cadell, 2010). When we inserted ‘maternal’ and ‘paternal’ separately into our search terms, more than six times as many articles were identified for bereaved mothers than bereaved fathers. More research is needed to better understand the experience of bereaved fathers, considering gender roles of men as ‘protectors’ who are ‘strong’ and meant to hide their feelings. It may be that conventional measures focusing on psychological functioning do not fully assess how men cope with the death of a child, especially given that several studies suggest lesser intensity of grief-related symptoms among fathers (Dyregrov & Matthiesen, 1991; Michon et al., 2003; Schwab, 1996; Theut, Zaslow, Rabinovich, Bartko, & Morihisa, 1990; Vance et al., 1995; Youngblut, Brooten, Glaze, Promise, & Yoo, 2017), with a dominant coping focus on work and performing tasks, and more work absences due to somatic illness (Wilcox et al., 2015).

In relation to diagnostic formulations, Persistent Complex Bereavement Disorder in the DSM-5 (American Psychiatric Association, 2013) and PGD in the ICD-11 (http://ICD.who.int) cannot be diagnosed until 12 months and 6 months post-loss, respectively. Considering studies have shown that parental grief is severe and long (e.g., Lannen et al., 2008) these time limits seem particularly short, potentially pathologizing the experience of the majority of bereaved parents. Longitudinal studies would provide a better understanding of trajectories of parental grief, helping to define those experiences that are considered ‘normal’ and ‘expected’. We have shown that high levels of symptoms persist for 4 years following sudden and unexpected death (Goldstein et al., 2018). Similarly, prospective studies could provide important insight about pre-existing individual factors that might either facilitate healthy coping or negatively impact coping, highlighting opportunities for early intervention.

A clearer understanding of the trajectory of parental grief, the impact of individual factors on this experience and specific risk factors, would also allow for the development of universal bereavement services to facilitate adjustment within a prevention framework (Morris & Block, 2015). Psychologists and other mental health clinicians in medical settings can play an important role in developing and implementing such services, tailored to the unique needs of bereaved parents, paying particular attention to risk screening, especially following a sudden or traumatic death. Not only are psychologists in a position to raise awareness about the needs of young bereaved parents, but they can also provide individual outreach and treatment as needed and/or facilitate support group programs designed to decrease isolation by providing opportunities for bereaved parents to meet with other parents who are dealing with the same type of loss.

Conclusions

Evidence is consistent that severe grief reactions and highly symptomatic adjustment are prevalent and arguably normative in bereaved parents, especially following sudden and unexpected death. The severity of the typical experience of bereaved parents warrants further investigation to better understand both normative outcomes for mothers and fathers and grief outcomes indicating dysfunction, in this specific subset. Research is needed to understand whether current diagnostic criteria for complicated or prolonged grief conditions discern the most strongly affected young parents with specificity. Definitive evidence may be lacking to establish whether the grief experience of young parents is a distinct subtype but it can be concluded that further research is needed to directly address this question. This lack of evidence also creates risk of pathologizing large numbers of bereaved parents because the challenges unique to their category of loss are not fully recognized.

Finally, the invisibility of recently bereaved parents in clinical venues must also be considered. They do not readily present to health settings for help and yet have high levels of grief. Developing a universal and coordinated approach to identification that includes all relevant agencies involved following the death of a dependent child would facilitate early intervention. While important questions remain about the relationship between normative grief experiences and pathological levels of grief following the loss of a child, it seems timely that psychologists and other clinicians turn their attention to helping prevent an even more difficult bereavement in these young parents who have suffered a profound and unbearable loss.