Death of a Parent During Adulthood Peer Reviewed

• Journal List
• BMC Palliat Care
• v.16; 2017
• PMC5553589

BMC Palliat Care. 2017; xvi: 39.

When a parent dies – a systematic review of the furnishings of back up programs for parentally bereaved children and their caregivers

Ann-Sofie Bergman

^aneDepartment of Social Piece of work, Swedish Family unit Care Competence Centre, Linnaeus Academy, SE-351 95 Vaxjo, Sweden

Ulf Axberg

²Department of psychology, Academy of Gothenburg, SE-40530 Gothenburg, Sweden

Elizabeth Hanson

³Swedish Family Intendance Competence Middle, Linnaeus University, SE-391 82 Kalmar, Sweden

⁴Academy of Sheffield, Sheffield, United kingdom

Received 2016 Dec 20; Accepted 2017 Jul 31.

Abstract

Background

The death of a parent is a highly stressful life issue for bereaved children. Several studies have shown an increased risk of mental ill-health and psychosocial problems among affected children. The aims of this written report were to systematically review studies about effective support interventions for parentally bereaved children and to identify gaps in the research.

Methods

The review'southward inclusion criteria were comparative studies with samples of parentally bereaved children. The focus of these studies were assessments of the effects on children of a bereavement support intervention. The intervention was directed towards children 0–18 years; but information technology could likewise target the children's remaining parent/caregiver. The study included an outcome measure that dealt with furnishings of the intervention on children. The following electronic databases were searched upwards to and including Nov 2015: PubMed, PsycINFO, Cinahl, PILOTS, ProQuest Sociology (Sociological Abstracts and Social Services Abstracts). The included studies were analysed and summarized based on the post-obit categories: type of intervention, reference and grade of evidence, study population, evaluation design, measure out, effect variable and findings equally consequence size within and between groups.

Results

K, seven hundred and-vi abstracts were examined. Following the selection process, 17 studies were included. The included studies consisted of 15 randomized controlled studies, while one report employed a quasi-experimental and one study a pre-mail-exam design. Thirteen studies provided stiff evidence with regards to the quality of the studies due to the grade criteria; three studies provided fairly stiff evidence and one written report provided weaker evidence.

The included studies were published between 1985 and 2015, with the majority published 2000 onwards. The studies were published within several disciplines such every bit psychology, social work, medicine and psychiatry, which illustrates that back up for bereaved children is relevant for dissimilar professions. The interventions were based on various forms of support: grouping interventions for the children, family interventions, guidance for parents and camp activities for children. In fourteen studies, the interventions were directed at both children and their remaining parents. These studies revealed that when parents are supported, they can demonstrate an enhanced chapters to support their children. In iii studies, the interventions were primarily directed at the bereaved children. The results showed positive between group effects both for children and caregivers in several areas, namely large effects for children'due south traumatic grief and parent'southward feelings of being supported; medium effects for parental warmth, positive parenting, parent's mental health, grief discussions in the family, and children's wellness. In that location were pocket-sized furnishings on several outcomes, for instance children's postal service-traumatic stress disorder (PTSD) symptoms, anxiety, depression, self-esteem and behaviour problems. There were studies that did not prove furnishings on some measures, namely depression, present grief, and for the subgroup boys on feet, depression, internalizing and externalizing.

Conclusions

The results indicate that relatively brief interventions tin can foreclose children from developing more than astringent bug subsequently the loss of a parent, such as traumatic grief and mental health problems. Studies have shown positive effects for both children's and remaining caregiver's health. Farther inquiry is required including how best to support younger bereaved children. There is also a need for more than empirically rigorous effect studies in this surface area.

Keywords: Bereavement, Grief, Parental death, Death, Dying, Bereavement support, Intervention, Evaluation

Groundwork

In stable developed nations about 3 to 4 % of children are afflicted by the loss of a parent through death prior to the age of 18 [1]. The loss of one or both parents can be associated with a higher vulnerability for children, both from a short and long term perspective. Several studies have shown an increased adventure of mental health problems and threats to emotional well-beingness for affected children, such as feet, depression and a perceived lack of control over what happens in ane'due south life [1–v]. The death of a parent has too been linked to increased somatic symptoms and development of stress sensitivity [2, 6, 7]. Scandinavian studies accept revealed that the death of a parent in childhood or adolescence is associated with an increased mortality run a risk during childhood, adolescence and into early adulthood [eight, 9]. Parental death in babyhood is also associated with an increased long-term risk of suicide [10]. A kid's problems postal service bereavement may also appear in school as concentration difficulties or behavioural problems [ane, 2]. A longitudinal written report by Brent et al. [11] reported that suddenly (e.k. unexpected deaths) bereaved youths had lower competence than non-bereaved youths in the areas of work and future pedagogy planning.

After the death of a parent some children live with their remaining parent, while other children live with another person, for example a stepmother, stepfather, grandparent, aunt, uncle, sibling, foster parent, adoptive parent. In this article we use the term caregiver to refer to a surviving parent or some other significant other who takes on board a parental role.

The decease of a parent is a highly stressful life event for children. While children at this time are in significant demand of support, the inverse can happen because of changes in the family unit situation and family unit roles post bereavement. In some cases, the children's remaining parent/caregivers are struggling with their own grief and may feel psychological difficulties themselves. As a result, it tin be a challenge for them to provide sufficient support for the children. The remaining parent must also bargain with boosted stressors of being a single parent and the sole provider of back up, while simultaneously coping with the loss of their partner [12]. For the children, this can hateful reduced time, attention and support from their remaining parent/caregiver.

Some children, who lose a parent under traumatic circumstances (such as deaths due to violence, suicide, blow, war or disaster), may endure from traumatic grief. In some instances, death from natural anticipated causes may also result in traumatic grief, if the child's experience of the expiry was shocking. The children can re-experience the traumatic event through intrusive memories, thoughts and feelings. The distress leads to avoidance of trauma and loss reminders. The child may avoid thinking or talking about the deceased parent, places and activities associated with the parent. The traumatic experience oftentimes complicates the children'due south grieving procedure [13]. After the loss of a parent children tin as well develop prolonged grief disorder, a disorder that includes a persistent and disruptive yearning [14]. The kid may too take difficulties in accepting the parent's death and difficulties in moving on in their own lives. The child may also feel feelings of bitterness, and a sense that life is meaningless as office of the syndrome detachment [fourteen].

When a parent dies, the children and the remaining parent/caregiver may need communication and back up in their grieving process from a health intendance professional, in order that their mental health needs are met and so that they tin keep their development in a positive direction. However, a key question in the field is what kinds of support are most effective for the children and their caregivers?

While previous reviews in the field take had a broader focus, namely treatment furnishings for children who have lost a "loved ane", such as a family member, grandparent, relative or friend [15–17], the review presented in this paper focuses on the furnishings of support interventions for children who are parentally bereaved. The rationale for this in-depth focus is that it is recognised that at that place are distinct difficulties for children losing a parent and caregiver, every bit this is often the person that previously was central in the provision of love, security and daily intendance. This closer relationship means college impact for the child and heightened feelings of loss and bereavement [2].

In this paper, nosotros nowadays findings from a systematic review of empirical studies evaluating the effectiveness of supportive interventions for children when a parent or caregiver dies. In so doing we may identify gaps in the research. Our research questions are: Which support interventions accept been evaluated that focus on effects for children? What is known about the effects of support interventions for the children? What are the needs for farther research in the field?

Method

Our review inclusion criteria were studies:

1. Published in English language or Scandinavian languages.

2. Sample populations of parentally bereaved children to 18 years of age.

3. Evaluating the effects of bereavement interventions for the children. Family programs were included if children were included in the intervention and the evaluation.

4. Those were randomized controlled design, quasi experimental design or pre-mail service-test pattern.

Working with an information specialist at the National Board of Health and Welfare Sweden, a systematic literature search was undertaken in April 2013 to place relevant references. Six electronic databases were searched, PubMed, PsycINFO, Cinahl, PILOTS, ProQuest Sociology (Sociological Abstracts and Social Services Abstracts). An updated database search was undertaken in November 2015 to identify studies of bereavement back up interventions. We used search terms including: bereavement; grief; parental death; parental bereavement; parentally bereaved child; parentally bereaved youth; parental loss; dying parents; loss of a parent; childhood bereavement; children'south grief; grieving child; combined with search terms related to interventions and evaluation (For full details please contact the first writer). Reference lists in the identified literature and previous reviews in the field were also scanned to locate boosted relevant studies.

During the option of studies The Cochrane Handbook for Systematic Review of Interventions (http://handbook.cochrane.org/) was used as a guide. All retrieved studies were reviewed independently past ii of the authors. In the initial screening stage, only studies that were obviously irrelevant were excluded. In cases where the researchers made different selections, the studies were included for further review past two authors reading the total newspaper. In the case of disagreement, ii researchers discussed the studies until consensus was reached. Studies were excluded for the following reason: the study population in the evaluation was minor, i.e. studies with a population of less than thirty participants.

The evidence was graded co-ordinate to the rigour of the written report design and analysis. We used the same grading criteria as Harding & Higginson [eighteen] and Hudson et al. [19] in their reviews of intervention studies [20]. The assessment and grading criteria are shown in Tabular array ​ one.

Table one

Form Criteria

Grade I (Strong evidence)  RCTs or review of RCTS   IA Calculation of sample size and authentic standard definition of appropriate event variables   IB Accurate and standard definition of advisable outcome variables   IC Neither of the above

Form 2 (Fairly strong evidence)  Prospective report with a comparison group (not-randomized controlled trial, good observational study or retrospective study that controls effectively for confounding variables)   IIA Calculation of sample size and authentic, standard definition of appropriate outcome variables and adjustment for the effects of important confounding variables   IIB One or more of the above

Grade III (Weaker evidence)  Retrospective or observational studies   IIIA Comparison grouping, calculation of sample size, accurate and standard definition of appropriate outcome variables   IIIB Two or more of the above   IIIC None of these

Grade IV (Weak bear witness)  Cross-sectional report, Delphi practise, consensus of experts

Cancer Guidance Subgroup of the Clinical Guidance Outcomes Group. Improving outcomes in breast cancer – the research evidence. Leeds: NHS Executive, 1996 [20]

Data analysis

Our analysis of the included studies were grouped in a table based on the following categories: type of intervention, reference (comparison), course of evidence, study population, evaluation pattern, measure, outcome variable and findings as effect size within (at baseline and follow-upwardly) and between study comparison groups.

For any ordinal or continuous variables, to be able to calculate outcome size even when a means and standard divergence were non reported in studies, the standardized mean difference outcome size for within-subjects design was used, which is referred to equally Cohen'southward d_z. The consequence size gauge Cohen'south d_z. can be calculated directly from the t-value using the formula d z = t / northward . A commonly used interpretation of Cohen's d is that value of 0.2 can be considered a small effect, 0.5 a medium consequence and 0.8 a large effect [21].

The Mutual Linguistic communication effect size (CL) [22] is too reported. The CL is as well known equally the probability of superiority [21], represents the probability in percent that a randomly selected person will score a different observed measurement mail service- than pre intervention, after controlling for individual differences. In addition when possible, the result size of difference between groups was calculated (dm) using a method proposed past Morris in which effect size is calculated on the mean pre-post change in the treatment group minus the mean pre-postal service change in the command group, divided by the pooled pre-test standard deviation [23]. For chiselled information, Chi-squared tests were made. Phi is reported as the effect size proposed by Fritz and colleagues using the formula φ = χ 2 N ′ [24]. A value of 0.i is considered a minor event, 0.iii a medium effect and 0.5 a large upshot.

Results

The total number of citations identified in the database searches in April 2013 was 1706. Following the screening process, 371 references were selected for further review of full texts. After exam of full texts, a total of 15 studies were identified that evaluated the effectiveness of bereavement interventions with parentally bereaved children [25–39]. We identified an boosted study from checking of the reference lists [40]. The number of citations generated in the updated search in November 2015 was 921. Of these 5 citations were reviewed in total texts. An additional relevant report was identified [41], resulting in a total of 17 selected studies for the review, encounter Fig. ​ one beneath.

Included studies

The included 17 studies were published between 1985 and 2015, the bulk, 13 were published after 1999. Nigh studies were conducted in the United States [26, 27, 29–39, 41]; two in England [25, twoscore], and another was an international collaborative report involving Iran, Britain and Norway [28].

Quality of included studies

The studies differed; they were based on different report designs, contained a variety of effect measures and varied in quality. Co-ordinate to our quality grading criteria (Table ​ ane) [eighteen–20] 13 studies provided strong evidence. These studies were randomized controlled trials involving validated measures. Iii studies provided fairly strong bear witness and one study provided weaker show [18–20]. Two of the included bereavement interventions were evaluated with a population of more than 100 children. Namely, "The Parent Guidance Programme" [26] and "The Family Bereavement Program" [27, 29, thirty, 33–35, 37, 39, 41]. Ane of the interventions, Family Therapy sessions, was tested in ii papers [25, 40] and one, The Family Bereavement Plan, in every bit many as 10 papers [27, 29, thirty, 33–35, 37–39, 41].

Study design

I study employed a quasi-experimental blueprint [31] and one study had a pre-test/post-test design [36], the others were randomized controlled trials. What the intervention was compared with varied: no intervention [25, 28, 40]; delayed handling [31, 32]; a phone support intervention [26]; and a self-study program [27, 29, 30, 33–35, 37–39, 41].

The core concepts addressed in the effect measures were:

• Children's wellness, in particular their mental health (internalization, externalization, coping, stress, cortisol-levels)

• Children'due south grief symptoms (traumatic grief, problematic grief)

• Children's behaviour and school problems

• Children's self-esteem

• Children'due south concepts of expiry and communication about the deceased parent

• Parenting (communication, caregiver-child human relationship, parental warmth, acceptance, consistent discipline)

• Caregiver's mental health

L dissimilar outcome measures were employed. Nosotros nowadays the most commonly reported outcomes in the included studies which focus on children's health, behaviour, grief, self-esteem, parenting factors and caregivers' mental wellness [42–54] (see Table ​ two below).

Tabular array 2

The most common event measures employed in the included studies

Children's health and behaviour	Child Behaviour Checklist (CBCL) [42] Children's Depression Inventory (CDI) [43] Youth Cocky-Written report (YSR) [42] Children's Manifest Anxiety Scale-Revised (R-CMAS) [44]
Children's grief	The Extended Grief Inventory (EGI) [51] Intrusive Grief Thoughts Scale (IGTS) [52] Adapted Inventory of Traumatic Grief: Symptoms of prolonged grief disorder (ITG) [45] Traumatic Grief Inventory for Children (TGIC) [46] The Texas Revised Inventory of Grief (TRIG) [47]
Children'south self-esteem	The Self Perception Profile for Children (SPPC) [53]
Parenting factors	Children'south Reports of Parental Behaviour Inventory (CRPBI) [48] Parent Perception Inventory (PPI) [54]
Caregiver'southward mental wellness	Brook Low Inventory (BDI) [49] Psychiatric Epidemiology Research Interview (PERI) [l]

Interventions

A key research question for this review is: What types of support interventions were evaluated in the studies? We institute studies varied in their theoretical under-pinning and aim. They likewise took diverse forms: group interventions for the children [28, 36], family interventions [25, 27, 29, 30, 32–35, 37–41], parental guidance [26], and camp activities for children [31].

Some interventions were designed based on resilience, risk and protective factors for parentally bereaved children [27, 29, thirty, 32–35, 37–39, 41]. Others were based on theory of trauma and/or the grieving procedure [28, 31]; psycho-education [26]; psychodynamic theory [36]; and zipper theory [25, xl]. To a large extent, the interventions were directed towards children at an early stage in their grief process. "The Family Bereavement Program" and "The Parent Guidance Program" were explicitly intended to be preventive interventions [26, 33]. Notwithstanding, the intervention "Writing for recovery" was directed at refugee children with high symptoms of traumatic grief [28]. For some of the refugee children, many years had passed since their parents died.

In 3 of the studies, the interventions were primarily directed at the bereaved child in the form of back up groups and/or camp activities [28, 31, 36]. The intentions in these studies were: to provide emotional back up; to normalize the children'due south experiences after the loss; to provide a safe environment where the child can limited emotions and thoughts; to facilitate the child's grieving process and to aim to improve the child's physical and mental health. For further description of the interventions, see Table ​ 3.

Tabular array three

Intervention description

Written report	Intervention description
Schilling et al. 1992 [36] (USA)	Grouping intervention, "Bereavement groups for inner-city children" Groups consisting of vi–eight children, historic period 6–12 years 12 sessions divided into three phases, each of four sessions Opening phase: rules of confidentiality, conduct, purpose of the group; focus on the children's relationship to the deceased and the impact of the loss on their family; sharing experiences related to death; supportive environment; normalizing bereavement bug Working phase: focus on children'southward feelings of sadness, anger, ambivalence related to the loss; demystifying irrational thoughts and fears near the expiry; identifying and expressing painful feelings Ending phase: the termination of the group as another loss; encourage children to apply their family as support organisation; children were reassessed to determine the need for further treatment
McClatchey et al. 2009 [31, 55] (United states)	Group intervention, camp activities, "Military camp MAGIC" Groups consisting of 5–eight children, separate groups for children age 7–11 and 12–17 years Camp activities: such as ropes course, canoeing, archery, interacting with new friends Counseling sessions: half-dozen counseling sessions during a weekend (Friday-Sunday) Focus on: trauma experience; trauma and loss reminders; mail-traumatic adversities; interplay of trauma and grief; resumption of developmental progression Grief-oriented tasks and cognitive behavioural aspects such every bit exposure, cognitive restructuring, stress inoculation techniques Activities: related to grief processing such every bit cosmos, play, puppetry testify, memorial service Psychoeducational workshop for parents well-nigh children's grieving process
Kalantari et al. 2012 [28] (Iran/Great britain/Norway)	Group intervention "Writing for recovery" Intervention for children age 12–18 years half-dozen sessions in schoolhouse during three consecutive days, each day consists of 2 15-min sessions Writing about traumatic experiences to decrease negative thoughts and feelings Writing sessions: Progress from unstructured expressive writing about innermost feelings and thoughts about the traumatic result/loss, to more than structured writing where children reflect on what they would have given as advice to some other in the same situation every bit themselves. In the concluding writing session children are asked to imagine that 10 years has passed and they look back and recollect about what they have learned from their feel
Blackness & Urbanowicz 1985 [40]; Black & Urbanowicz 1987 [25] (United kingdom)	Family unit intervention, family therapy sessions, with children age 0–sixteen years and their families 6 family therapy sessions spaced at 2–3 weeks intervals, in the families' homes Focus on: help with emotional and applied problems arising from bereavement; promote mourning in both children and surviving parent; better advice betwixt children and parent; improve communication about expiry; encourage children to talk most the dead parent and their feelings of loss and grief; encourage expression of grief in the family unit Separate sessions for parents alone to enable him/her to talk nearly his/her own grief, anger, needs
Christ et al. 2005 [26] (Usa)	Intervention directed to the well parent and the family when a parent has cancer and is terminally ill, "The Parent Guidance Program" Families with children historic period 7–17 years vi or more than 60–90 min therapeutic sessions during the concluding phase of the parents illness and vi or more sessions after the parents expiry, including meetings with parent(s), children and family Focus on: to affect the children'southward adjustment to the loss by enhancing the surviving parents ability to sustain competence in providing back up and intendance or the children; provide an environment in which the children feel able to express painful or conflicting feelings, thoughts, fantasies almost the loss; maintain consistency and stability in the children's environment; support to parents in their ain grief piece of work in order to enhance their capacity to part effectively during the family crunch; problem solving around the immediate crisis; communication nearly illness, loss, grief, reactions; futurity planning for the family
Sandler et al. 1992 [32] (USA)	Family intervention "The Family Bereavement Programme" Intervention for families with children age 7–17 years Program including a total of 13 sessions, consisting of a family unit grief workshop and a family unit adviser program Family grief workshop, with eight bereaved families per session Focus on: to fulfil the perceived needs of bereaved families to meet with other families who have like experiences; to better warmth in the parent-child relationship; meliorate communication about grief experiences Family adviser program, 12 sessions, including 6 individual sessions for parents and 6 family unit sessions Focus on: parental support; provide emotional support; decrease parental demoralization; increase warmth of the parent-child human relationship; increase positive exchanges between family members; increasing quality time betwixt parent and child; communication in the family; planning of stable events; helping meliorate coping with stressful family events
Sandler et al. 2003 [33]; Schmiege et al. 2006 [37]; Tein et al. 2006 [39]; Sandler et al. 2010 [34]; Sandler et al. 2010 [35]; Luecken et al. 2010 [29]; Hagan et al. 2012 [27]; Schoenfelder et al. 2013 [38]; Luecken et al. 2014 [xxx]; Schoenfelder et al. 2015 [41] (USA)	Family intervention "The Family Bereavement Program" Intervention for families with children age 8–16 years Plan including a total of 14 sessions, consisting of 12 sessions in separate groups for caregivers, children and adolescents Four of these include conjoint activities for children and caregivers. The program also include two private family meetings Groups consisting of 5–9 children, separate groups for children age viii–12 and 12–16. Sessions for caregivers Focus on: improving positive caregiver-child human relationship; positive parenting; constructive discipline strategies; coping with grief; talking to children about grief; increase positive activities; reduce children's exposure to negative events; family routines; family unit time; one on i time; communication; listening skills; decrease caregiver mental wellness problems Sessions for children Focus on: improving caregiver-child relationship; positive coping; coping efficacy; control-related behavior; cocky-esteem; reduce negative appraisals for stressful events; provide opportunities for expression and validation of grief-related feelings; encouraging sharing of feelings with caregivers; individual goals selected past the children

In the majority of the included studies, the interventions were directed at both the kid and their remaining caregiver [25–27, 29, 30, 32–35, 37–41]. The intentions in the included studies were: to provide support for the children and their caregivers; to ameliorate family unit communication and the caregiver–kid relationship; to facilitate participants' grieving process; to improve their health; strengthen parenting; increase stability and predictability for the children; and to reduce the occurrence of negative events among the children (run into Tabular array ​ three).

In general, the interventions were brief. The shortest program was "Writing for recovery", involving two fifteen-min sessions in school during three consecutive days, each mean solar day consisted of ii sessions (i.east. six xv-min sessions and a total of ninety min) [28]. The camp-based program "CampMAGIC" was delivered over a weekend [31, 55]. The longest, "The Parent Guidance Program" lasted a year, it began when the parent was sick, and continued during the terminal illness and at least 6 months afterwards the parent's death [26]. It involved at least 6 sessions during the terminal affliction and six subsequently the parent had died. The other interventions were based on a full of 6–14 sessions (see Table ​ 3 for more details).

All interventions were professionally led, in virtually cases by social workers or counsellors with extensive experience of working with child guidance, grief or psychiatry. The highest educational attainment of professionals were those who led "The Family Bereavement Program", who had at least a chief'south caste [34]. In several studies the intervention leaders received supervision in the implementation of the support program [26, 32, 33, 36].

Written report population

The included interventions in this review were directed at children from schoolhouse age upwardly to 18 years of age. This is with the exception of two studies where younger children (0–16) were involved in family therapy sessions [25, twoscore]. Most of the studies concerned children who had experienced a parental death from a range of causes, namely illness, blow, suicide or homicide [25, 27, 29, 30, 32–41]. Ordinarily parents died because of an illness (65–82%), thereafter due to an blow (15–20%) or suicide/homicide (x–xiv%). In most studies there was a lack of information most what kind of affliction the parent suffered from, where at that place was information, diseases included those of the heart and cancer [25, 32, 40]. One study compared intervention furnishings for children who had lost a parent to expected versus unexpected deaths [31]. One study focused on children during their parent'due south terminal cancer illness as well as after the parent'south decease [26]. Finally i study focused on support directed at refugee adolescents who had lost their parents in state of war [28]. Except for this evaluation directed at refugee children from Transitional islamic state of afghanistan, the majority of included studies had samples that were various in ethnicity, including for example Caucasian, Hispanic, African American, Native American, Asian/Pacific and other ethnicities [33].

In the studies, the well-nigh common deceased parent was the child's father with the remaining caregiver being the female parent. In two of the studies, women as remaining caregivers were over-represented as participants in the study populations [32, 36]. In one study 86% of the deceased parents were fathers and 14% mothers [32]. In some other written report, fathers as remaining caregivers only represented 5 % of the sample [36].

Effectiveness of the interventions

Another primal research question for this review was: What is known about the furnishings of support interventions that are targeted at/or include support for parentally bereaved children? The included studies were analysed and summarized in a matrix. The results are presented in tabular array form (come across Table ​ 4 beneath). In that location were 12 studies that analysed effects inside and between trial arms, while five studies analysed moderating and mediating factors. The latter are excluded from the analysis of effects in Tabular array ​ 4, but are notwithstanding informative and are therefore included in the article. Our focus is on comparing differences betwixt groups, simply nosotros take also chosen to present results within groups in Table ​ iv, as this may be relevant from a benchmarking perspective, both for researchers and clinicians [56]. The results from the analyses of included studies revealed positive furnishings of the support interventions both for the children and their remaining caregivers in several areas.

Table 4

Study effects within and between treatment groups

Interventions directed to the bereaved children
Intervention	Reference and grade of evidence	Study population	Evaluation design	Measure	Outcome variable	Effect size TG			Event size CG			Effect size betwixt groups
						sig	dz	CL %	sig	dz	CL %	sig	dm (ϕ)
"Bereavement groups for inner-city children"	Schilling et al. 1992 [36]	38 children (historic period vi–12)	Pre-test/post-exam-design	BID	Depr. (Parent) Depr. (Child)	.26 .29	−.22 .21	−59 58	na na	na na	na na	na na	na na
	IIIC		Evaluation: postal service treatment	ATCD	Attitudes and Concepts of Death	.01	.52	70	na	na	na	na	na
Grief campsite "Military camp MAGIC" (CG) delayed treatment	McClatchey et al. 2009 [31]	100 children (historic period half dozen–16)	Quasi experimental design	UCLA PTSD	PTSD-symptoms	.08	.33	63	.73	−.05	52	.08	.27
	IIB	TG = 46 CG = 54	Evaluation: post handling	EGI	Childhood Traumatic Grief	.00	.73	77	.90	−.02	51	.01	.fifty
"Writing for recovery" (CG) no treatment	Kalantari et al. 2012 [28] IB	61 children (age 12–xviii) TG = 29 CG = 32	RCT Evaluation: i week mail service handling	TGIC	Traumatic grief	.00	1.26	90	.03	−.39	65	.00	1.21
Family-intervention (CG) no treatment	Black & Urbanowicz 1985 [40]; 1987 [25] IIB	83 children (age 0–sixteen) TG = 38 CG = 45 45 families TG = 21 CG = 24	RCT Evaluation: one year postal service handling	Clinical Interview	Beliefs Slumber Depressed parent	na na na	na na na	na na na	na na na	na na na	na na na	.05 .09 .01	(.21) (.21) (.33)
					Talk nigh dead parent	na	na	na	na	na	na	.04	(.26)
				Rutter A Rutter A	Restless Blast-bitter	na na	na na	na na	na na	na na	na na	.01 .03	(.34) (.28)
					Schoolhouse issues	na	na	na	na	na	na	.10	(.19)
Family-intervention (CG) no treatment	Black & Urbanowicz 1987 [25] IIB	73 children (age 0–16) TG = 38 CG = 35 39 families TG = 21 CG = 18	RCT Evaluation: two years post treatment	Clinical Interview	Behavior Talk dead parent	na na	na na	na na	na na	na na	na na	.09 .04	(.28) (.24)
					School Health	na na	na na	na na	na na	na na	na na	.03 .04	(.28) (.39)
"Parent Guidance Plan" (CG) telephone monitoring intervention	Christ et al. 2005 [26] IA	104 families with children (age vii–17) TG = 79 CG = 25	RCT Evaluation: viii and xiv months after parent's death	CDI SEI STAI-S STAI-T CBCL-soc	Low Cocky-Esteem State anxiety Trait anxiety Social competence	.00 .00 .00 .00 .29	.56 .64 .89 .61 .17	71 74 81 73 57	.03 .21 .12 .87 .27	.48 .29 .35 .04 −.31	69 61 64 51 62	.53 .36 .12 .31 .32	.14 .28 .44 .43 .36
				CBCL-bprob	Beliefs problem	.17	.16	59	.80	−.07	53	.69	.26
				POPM-tot	Perceived Parenting	.06	.25	60	.31	−.22	59	.11	.37
"The Family Bereavement Program" (first version) (CG) delayed treatment	Sandler et al. 1992 [32] IB	72 families with 72 children (age seven–17) TG = 35 CG = 37	RCT Evaluation: post treatment	CRPBI PRS PRS	Par. warmth Grief give-and-take Par. Support	.00 .78 .00	.97 .07 .88	83 53 81	.25 .00 .xi	.22 −.70 −.31	59 76 62	.03 .03 .01	.50 .62 .83
"The Family Bereavement Program" (revised version) (CG) self-written report program	Sandler et al. 2003 [33] IA	156 families TG = ninety CG = 66 244 children (age 8–xvi) TG = 135 CG = 109	RCT Evaluation: Posttest and 11 months mail treatment	Posttest
				Comp. GLESC Comp. Comp. AIS TAS SPPC MCPCS CBCL CBCL	Pos. parenting Negative events Ment. health Positive coping Inhibition Neg. thoughts Self-esteem Command belieifs Internalizing Externalizing	na na na na na na na na na na	na na na na na na na na na na	na na na na na na na na na na	na na na na na na na na na na	na na na na na na na na na na	na na na na na na na na na na	.00 .03 .01 .02 .01 .78 .37 .72 .03 .11	.58a .43a .50a .xxxa .48a .05a .19a .06a .41a .28a
				11-mth
				Comp. GLESC Comp. Comp. AIS TAS SPPC MCPCS CBCL CBCL	Pos. parenting Negative events Ment.health Positive coping Inhibition Neg. thoughts Self-esteem Command belieifs Internalizing Externalizing	na na na na na na na na na na	na na na na na na na na na na	na na na na na na na na na na	na na na na na na na na na na	na na na na na na na na na na	na na na na na na na na na na	.03 .eleven .10 .20 .06 .xviii .sixteen .00 .61 .19	.39a .32a .32a .xviiia .39a .29a .27a .40a .10a .24a
"The Family unit Bereavement Program" (CG) cocky-study program	Schmiege et al. 2006 [37] IA	156 families TG = 90 CG = 66 244 children (historic period eight–16) TG = 135 CG = 109	RCT Evaluation: 3 and 11 months post handling		3-months
				CMAS-R	Anxiety Girls Anxiety Boys	.08a .17a	.32a .23a	59 57	.32a .04a	.20a .38a	56 61	.41c .25c	.eleven −.xiii
				CDI	Depression Girls Depression Boys	.xa .nineteena	.30a .22a	58 56	.28a .37a	.21a .17a	56 55	.58c .98c	.11 .06
				YSR	Externaliz. Girls Externaliz. Boys	.03a .08a	.39a .30a	61 58	.09a .05a	.34a .38a	59 61	.36c .lc	.08 −.03
				CBCL	Intrenaliz. Girls Internaliz. Boys	.00a .00a	.74a .48a	70 63	.01a .00a	.53a .69a	65 69	.88c .39c	.19 −.sixteen
				CBCL	Externaliz. Girls Externaliz. Boys	.00a .01a	.56a .43a	65 62	.07a .00a	.37a .57a	60 66	.43c .44c	.23 −.12
					11-months
				CMAS-R	Anxiety Girls Anxiety Boys	.02a .01a	.43a .44a	62 62	.80a .01a	.05a .48a	51 63	.06c .73c	.36 .02
				CDI	Depression Girls Depression Boys	.02a .07a	.41a .32a	62 59	.55a .05a	.12a .37	53 60	.16c .65c	.28 −.01
				YSR	Externaliz. Girls Externaliz. Boys	.08a .27a	.33a .nineteena	59 55	.89a .13a	-.03a .30a	51 58	.03c .45c	.36 −.08
				CBCL	Intrenaliz. Girls Internaliz. Boys	.00a .01a	.eightya .47a	72 63	.01a .00a	.57a .63a	66 67	.93c .58c	.20 −.10
				CBCL	Externaliz. Girls Externaliz. Boys	.00a .02a	.55a .42a	65 62	.32a .00a	.20a .69a	56 69	.elevenc .86c	.twoscore −.22
"The Family Bereavement Program" (CG) self-written report program	Luecken et al. 2010 [29] IA	139 children TG = 78 CG = 61 (age eight–16)	RCT Evaluation: 6 years post handling	Cortisol	Cortisol level before and afterward a conflict discussion task	na	na	na	na	na	na	.03b	.39b
"The Family Bereavement Programme" (CG) self-report program	Sandler et al. 2010 [34] IA	156 families TG = 90 CG = 66	RCT Evaluation: Mail-examination, 11 months and 6 years mail service treatment		Mail service (iii-months)
				TRIG IGTS	Present grief Intrusive grief	.19a .16a	-.xvia .17a	54 55	.09a .fiftya	-.23a .09a	57 53	.72c .43c	.05 .09
		244 children (age 8–16) TG = 135 CG = 109			11-months
				TRIG IGTS	Present grief Intrusive grief	.69a .00a	.05a .47a	51 63	.87a .12a	-.02a .21a	51 56	.88c .06c	.08 .27
					half dozen-years
				TRIG IGTS	Nowadays grief Intrusive grief	.00a .00a	.73a 1.30a	lxx 82	.00a .00a	.63a 1.08a	67 78	.75c .03c	.xiv .21
"The Family Bereavement Plan" (CG) self-study programme	Sandler et al. 2010 [35] IA	140 families TG = 78 CG = 62	RCT Evaluation: half-dozen years mail service treatment	DISC Compsite	Mental Disorder Externalizing Internalizing	na na na	na na na	na na na	na na na	na na na	na na na	.28b .02b .57b	nab .31b nab
		218 children TG = 116 CG = 102		RSE PERI BDI	Self-esteem Demoralization Low	na na na	na na na	na na na	na na na	na na na	na na na	.01b .03b .04b	.40b .42b .40b

Large effects

At that place were two studies with stiff evidence (from robust studies, run into definition in Table ​ 1, Grade criteria) that showed large effects between groups: for children's traumatic grief [28]; and parent'due south feelings of being supported [32].

Medium furnishings

Four studies showed medium furnishings between groups. Two studies with strong evidence showed medium effects for the parents: for parental warmth [32]; positive parenting [33]; parent's mental wellness [33]; and for grief discussions in the family unit [32]. The post-obit studies with fairly potent evidence showed medium effects: for children's traumatic grief symptoms [31]; restlessness [twoscore]; and children'due south wellness [25]. 1 study with adequately strong evidence showed medium effects for parental low [40].

Small effects

Some studies showed small-scale effects between groups. The post-obit studies with strong evidence showed small effects: for children'southward symptoms of intrusive grief [34]; children's PTSD symptoms [31]; self-esteem [26, 33, 35]; feet [26]; feet (girls) [37]; depression (girls) [37]; behaviour problems [26]; social competence [26]; externalizing [33, 35]; externalizing (girls) [37]; internalizing [33]; internalizing (girls) [37]; cortisol level before and after a conflict discussion chore [29]; negative events [33]; negative thoughts [33]; control beliefs [33]; positive coping [33]; inhibition [33]; perceived parenting [26]. Ane study with stiff bear witness showed modest effects for parent's low [35]; mental wellness [33]; demoralization [35]; and positive parenting [33]. The following studies with fairly strong evidence showed minor effects: for children'south behaviour bug [25, xl]; sleep problems [twoscore]; nail-biting [40]; talking about the dead parent [25, 40]; and schoolhouse problems [25, twoscore].

No furnishings and negative effects

In that location were a few studies that failed to reveal any effect on measures at any of the post-test or subsequent follow-upwards test periods. With "No outcome" nosotros mean studies where the between group event size were on Cohen'southward d between 0.00 and 0.nineteen and the effect size calculated as Phi betwixt 0.00 and 0.09. The following studies with strong evidence showed no effects on depression [26] and present grief [34]. One study did non show effects for the subgroup boys on the measures anxiety, low, internalizing and externalizing [37].

Finally ane study showed a small but negative upshot for boys' externalizing behaviour (−0.22), which means that the reduction of externalizing behaviour in boys 11 months post intervention was less in the intervention group than in the command grouping [37].

Discussion

The aims of this article were to systematically review empirical studies about effective methods of back up for children when a parent or caregiver dies and secondly, to identify gaps in the research. Seventeen studies were included in the review. The included studies were mainly randomized controlled studies, with the exception of two studies, 1 of which was a quasi-experimental written report and the other study employed a pre-post-test design. Thirteen studies provided strong bear witness with regards to the quality grading criteria, three provided fairly potent testify and ane provided weaker testify.

In this review we constitute large as well every bit moderate and small betwixt group furnishings for children and their caregivers. At that place were furnishings on children's grief symptoms, health, behaviour and self-esteem, as well as effects on parenting factors and caregiver's mental wellness. There were effects from group interventions directed at children [28], family unit interventions [25, 29, 32–35, 37, 40], parental guidance [26] and camp activities for children [31].

At that place were studies that did not bear witness effects on some measures, on low, present grief, and male child'southward feet, low, internalization and externalization. The latter results betoken a need to pay attention to possible gender differences. Notwithstanding, it should also be noted that several of the studies in the review consisted of pocket-size numbers of participants, indicating that there is a gamble that in some cases in that location might actually have been a difference between the intervention and control group, which may not have been detected due to the fact that samples were too small to find statistically significant differences when the effect sizes were small. It is also important to go along in heed that almost of the included interventions were primary or secondary preventive in nature. That is, they sought to foreclose the development of an illness or disease earlier it even occurred or lower the impact if indeed it already had occurred [57], and thus effect sizes could be expected to be pocket-size, merely nevertheless remain important for a large group of children [58].

The overall results suggest that even relatively cursory supportive interventions can prevent children from developing more severe problems later on the loss of a parent [34, 35]. The randomized controlled studies of "The Family Bereavement Plan" stand out among the included studies, as the intervention has been evaluated several times, with unlike outcomes and longitudinally (vi year follow-upward period) [27, 29, 30, 34, 35, 41]. After the first included effect study that was published in 1992, the support program has been later on revised and refined. The plan consists of a total of 14 sessions, including separate groups for caregivers, children and adolescents; joint activities for children and their caregivers; and individual family meetings [59]. The studies concerning "The Family Bereavement Program" from the yr 2003 and onwards business organization the same version of the support program whose effects have been evaluated from unlike perspectives. The evaluations of the programme also include fidelity of program implementation, assessed as attendance and implementation of the items described in the manuals [33]. The results showed positive effects for both children and caregivers. Studies of the program indicated that some children and families may require more intensive interventions [35, 41] or additional support [38] equally the intervention itself is brief.

The results of our review differ from previous reviews that have reported relatively small effect of supportive interventions for bereaved children [15–17]. 1 reason for the differing results may be that previous reviews oftentimes adopted a broader focus by including children who have lost other types of "loved ones", for case a family unit fellow member, grandparent, relative or friend [15–17], while this review is focused exclusively on parentally bereaved children. Another reason for the differing results may be that several studies included in previous reviews were excluded in this review for quality reasons, as in some studies the sample was as well small for the results to be generalizable. A third reason for the differing results is that some studies of high scientific rigour were published after the previously published systematic reviews. The latest systematic review nosotros found was published in 2010 [17], while eight out of 17 studies in this review were published during the period 2010–2015.

Implications for do

The included studies in this review were published inside several disciplines, namely psychology, social piece of work, medicine, psychiatry, lending weight to the statement that the subject of support for parentally bereaved children is relevant for a range of different professional person groups.

1 conclusion from this review of interventions is that in that location were studies that have shown effects for children and their caregivers. The results bespeak that supportive interventions tin be directed exclusively to the children or to both the bereaved child and the child'southward remaining parent or caregiver. Support for the children's caregivers tin strengthen their ain health and their capacity to back up their children. A supportive parenting is a protective resources for parentally bereaved children [threescore]. Previous research indicates that when the bereaved children's caregivers are supported, they demonstrate an enhanced capacity to support their children [60–62].

At the aforementioned fourth dimension, back up also needs to be directed at the children. In the evaluation of a parental guidance programme, the remaining parents expressed that they perceived a need for more support directed to their children [26]. In one of the included studies, both children and parents indicated that they wished to talk over grief-related experiences with other people who had similar experiences [32]. Being and connecting with other bereaved children tin be helpful for children who attend a back up group, equally it can help them to feel less isolated and alone [55, 63, 64]. Simultaneous family sessions involving both children and the remaining parent may be an of import component in a back up plan as such sessions are sometimes the first occasion that the parent and children accept had the opportunity to sit downward together and talk about the loss and their feelings about it [25]. Some children avoid talking about their problems or showing their feelings as they attempt to protect their remaining parent or other people around them. This can sometimes be misinterpreted as a sign that the child is not affected by the loss [65]. The included effect-evaluated interventions were non sufficient for all children. The bulk of intervention programs were cursory. Studies indicated that some children may need more intensive back up or additional back up [31, 35, 36, 38, 41]. Therefore, information technology is important to reassess children'due south farther needs for support at the cease of an intervention [36].

Implications for research

Given that there are currently relatively few scientifically rigorous studies in this area, there is a clear need for farther inquiry about the effects of support interventions directed at parentally bereaved children. Indeed, there were only 17 studies that met the criteria for this review. All studies, with the exception of one [28], were comprised of studies virtually English language interventions that were evaluated in the United states of america or UK (see Table ​ four). It is axiomatic that there is a need for more effect studies with longer follow-up, with the Family Bereavement Program being a notable exception, as children's bug tin appear afterwards and it may also have time before changes in the participant families stabilize post intervention and have an result for the children [33]. Furthermore, there is a need for studies with populations sufficiently large enough to make comparisons of the effects for various categories, so that the interventions can be modified to various children's needs. Some studies for case, showed differences in the efficacy of interventions for children at different ages [35, 41], for girls and boys [26, 33, 35, 37], for mothers and fathers [26] and for children with different levels of bug at baseline [35, 41]. In the bulk of included studies the sample were diverse in ethnicity, but did not analyse furnishings for different ethnic minority groups. The sample sizes of minority groups were too small to allow the testing of program effects for diverse groups [34]. In the studies, the most common deceased parent was the child's begetter with the remaining caregiver the mother. This is consistent with mortality statistic rates equally children under the age of eighteen are more likely to experience the death of a father than the expiry of a mother [1].

This systematic review highlights that interventions evaluated with a focus on effects for children have almost exclusively been directed at school age children, while the bereavement research shows increased risks for the youngest children when 1 or both parents dies [4]. The younger children are especially vulnerable as they are totally dependent on their caregivers. In addition, they often find it more difficult to encompass what has happened to their deceased parent and what this means [66]. Consequently, evolution of supportive interventions and evaluation of bereavement interventions for younger children is an important effect for further research. Involving younger children in evaluations of interventions may require innovative methods, where the children are given the opportunity to express themselves in a mode that is adjusted to their chapters and cognitive evolution. Such evaluations may too include qualitative interviews where the children tin can limited themselves in their own words or through creative methods such as art or play [63, 67]. Farther, children need to be enabled to participate in the research to develop knowledge about their experiences, to explore with children what they themselves perceive as helpful in the grieving process and what kinds of outcome measures are most important from their perspective. For example, few of the outcome measures in the included studies concerned children's physical health and somatic symptoms, their situation in school and their peer relationships. Information technology is also important that children accept the opportunity to exist involved in evaluations of back up programs as parental reports accept a tendency to underestimate children'due south bug and report less symptomatology in their children than do the children themselves [68]. Qualitative information from evaluations could as well be helpful to identify opportunities to improve electric current bereavement interventions.

Finally, studies of bereavement interventions for children are more generally focused on children that are living in a nuclear family, where i parent dies and the other parent is the child's remaining caregiver. Yet, there are likewise children who have lived with a single parent who dies, and there are children who lose both their parents through expiry. These children have to alter caregivers and residence. The death of a parent engenders secondary losses that occur as a result of the primary loss. When the child'due south only parent or both parents dice, the secondary losses are increased, in number and complexity [69]. Therefore, special attending is merited towards these groups of children. One explanation why these children are underrepresented in evaluation studies is that the largest proportion of children in the western globe live together with both their parents. It is difficult to comport evaluation studies with this vulnerable group of children.

Conclusion

The results of this systematic review of support interventions for parentally bereaved children indicate that relatively brief interventions may assistance foreclose children from developing more than astringent issues, such as mental wellness problems and traumatic grief subsequently the loss of a parent. Further enquiry is required including how to all-time support younger bereaved children. There is also a demand for more empirically rigorous studies in this area.

Acknowledgements

The review presented in this paper was undertaken by the Swedish Family Intendance Competence Heart, Linnaeus Academy, and commissioned and funded past the National Board of Health and Welfare Sweden every bit part of a major initiative to support health care regions in Sweden to implement the change in the Health Care Act. According to the Swedish Wellness Care Act (2010) health care professionals shall give special attention to children'southward needs for data, advice and support when their parent or another adult with whom the child lives unexpectedly dies [70]. The human action aims to highlight the needs of affected children and improve their state of affairs in the health care system, which is in line with the UN Convention on the Rights of the Child [71].

We would like to thank Maja Fredriksson Kärrman, information specialist at the National Board of Health and Welfare Sweden (NBHWS), who conducted the initial literature search and Ann-Louise Larsson, librarian at Linnaeus University, for assist with the updated literature search.

Funding

This review was commissioned and funded by the National Board of Health and Welfare Sweden.

Availability of data and materials

The data analysed in the current study is available from the corresponding author on reasonable request.

Abbreviations

AIS	Active inhibition scale
BID	Bellevue index of low
CAS	Child assessment schedule
CBCL	Kid behavior checklist
CDI	Children'due south low inventory
CMAS-R	Children'due south manifest anxiety scale-revised
Comp	Composite scale
CRPBI	Children's reports of parental behavior inventory
DISC	The diagnostic interview schedule for children
EGI	The extended grief inventory
GLESC	General life events schedule for children
IGTS	Intrusive grief thoughts calibration
MCPCS	Multidimensional measure of children's perceptions of control scale
PERI	Psychiatric epidemiology enquiry interview
POPM	Perception of parenting measure
PRS	Parent report scale
RSE	Rosenberg self-esteem calibration
SEI	Self-esteem inventory – curt form
SPPC	Self perception contour for children
STAIC	State-trait anxiety inventory for children
STAIY	Land-trait anxiety inventory for youth
TAS	Threat appraisal calibration
TGIC	Traumatic grief inventory for children
TRIG	Texas revised inventory of grief (Nowadays)
UCLA PTSD	University of California–Los Angeles postal service-traumatic stress disorder reaction index for the DSM-Iv for Children

Authors' contributiondue south

AB and EH were responsible for the design of the written report and the review process. UA contributed with the quantitative analyses of the included studies. AB was responsible for drafting the initial manuscript. UA and EH reviewed and provided regular feedback on the manuscript. All authors contributed to, read and approved the final manuscript.

Notes

Ethics blessing and consent to participate

Non applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they take no competing interests.

Publisher'due south Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

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