Parental Death During Adolescence

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.

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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%).

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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

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).