Openness of communication with children about death and dying

The preparation and communication children received regarding parental death varied across the studies. Open communication allowed time together, acknowledging the reality of the impending death.23 30 31 However, the death was a shock, even when forewarned.23–25 30 Being unprepared left children feeling isolated,23 25 30 even children who witnessed the death felt isolated and dissociated from what was happening.23 24

Following the death, some children were quickly informed,29 while others were not told until after the funeral.23 25 Reasons for delaying included a desire to protect the child and beliefs that children were too young to understand.23 24 Unhelpful euphemisms for death, such as 'going to sleep', 'he’s gone', 'he’s up there'25 30 were frequently used, with families often avoiding conversations, leaving children with unanswered questions about death, with some blaming themselves for the death.29

Regardless of their cultural backgrounds, children appreciated open communication within the family about their experiences and grief.24 29 Expressions of feelings and offers of support were helpful.32 Children from studies published in the UK, Canada and South Africa were helped when given information and involvement in funerals, viewing the body or planning to return to school.25 28–31 This was not mentioned in other studies. However, it is important to note that the way children are involved in communication and death rituals varies by culture. Seeing their parent helped children stop feeling scared, offered a chance to say goodbye and helped them to accept the finality of death, often described as a relief.25 29 30 Children appreciated friends and teachers attending the funeral and took comfort in the number of people present.25

Review findings further showed that many children enjoyed returning to school and appreciated friends acknowledging their loss and showing they cared.27 28 31 Some found it overwhelming, and others had no acknowledgement of their loss from peers and teachers.28 Empathy from peers made children feel less isolated and different.27 It was important to children that peers were authentic and approached their loss naturally and genuinely.27 Children sensed the taboo around death.28 For many peers, this was their first encounter with death,24 27 and the lack of knowledge and experience about death and grief was often felt.24 25 27 28 31 Peers were often unprepared to deal with their grief, not knowing what to say or how to react, adding to their isolation.24 27 28 This led some to withdraw from their social circles.29 Half the children in the Ugandan study were no longer attending school; some had to take on caring roles within the family and others had no money for school fees.26

Most children found that speaking with bereaved peers who could empathise, and relate to their loss, helped them cope by normalising their experience.24 27–31 Siblings were an important source of support, sharing similar emotions.30 Peers who had experienced parental divorce could empathise and understand somewhat the internal and social experience of losing a parent.27 However, children recognised that others who had not experienced a catastrophic loss could not understand the impact, making it more difficult to talk to them.27 28 30 31

Children’s challenges of managing change

Children returned to school while their families remained in disarray, experiencing drastic change, uncertainty and instability.27 28 Children reflected on changes to their perceived identity; they felt different from peers and were perceived as such, either 'fatherless' or 'motherless'.23 25 27 28 Increasing feelings of isolation made children feel incomplete, experience discomfort and unease, feel less than others, and embarrassed.23 27 28 Some hid the death, so they were not different and did not have to talk about their loss;23 24 27 29 they feared being rejected, causing upset or showing emotions.23–25 27 30 31 Children perceived they were treated differently, avoided, excluded from play or ignored because they were different.27 28 Some were treated as normal as if it had not happened, which helped.27 28 Although some were able to speak to peers about how they felt and were well supported,25 28 30 31 others refused to discuss the death with anyone.23 27 Conversely, for some the worst response was too much attention; they appreciated others' empathy, but perceived unwanted physical contact, excessive questioning and being forced to talk about their loss as uncomfortable.27 28

Children redefined their new normal, experiencing further losses and yearning for what they had lost in their deceased parent.23 25 29 32 Some moved home,23 25 26 and relationships and roles changed.25 27 28 Those orphaned faced increased responsibilities, lacked stability, lost childhood, education, future hopes, and worried about who would care for them.26 Children who were living with different relatives often felt unwanted.25 26 Some experienced family conflict, social stigmatisation, and physical and emotional abuse.23 26 Social stigmatisation or being treated differently because of their bereavement was not found to be related to the cause of death or country.23 26–28

A consistent relationship with their parent or another adult was crucial.24 31 However, relationships with their parents changed, the family restructured itself, and their individual and family needs could not be met in the same ways, with strains on relationships.23 32 Some felt fortunate to have a parent to care for them29 and had a strong need for their attention.32

Navigating emotions

Family dynamics changed following a parental death, resulting in insecurity and worry.23 25 Some children saw parents struggling, hearing them secretly crying, failing in their new roles, and witnessing psychological breakdowns, including self-harm, attempts of suicide and depression.23 Some children modified their behaviour and were 'good' to prevent their parents from becoming upset,25 or did more to help their surviving parent.29 30 32 Others acknowledged how well their parents coped and adapted to their new roles.25

Many children suppressed their emotions23 25 27 30 32 and felt isolated, grieving alone.23 30 Children’s reactions to grief were individual and included physical, behavioural, emotional and spiritual reactions, while some showed little or no emotion at times.24 29–31 Some children struggled to understand that their grief responses and needs differed from their siblings, while others recognised that grief is unique and individual.31 Some children believed that managing their emotions, clarifying values and goals, accepting what had happened, and coping strategies contributed to their psychological well-being.24 Following their loss, some children found they expressed their own emotions more and were more thoughtful of the needs of others, with increased sympathy and sensitivity towards others' feelings, especially their immediate family, which brought them closer together.24 32

Children’s acceptability, access and engagement with support

Some children found their grief was a constant companion, never going away, and worsening at times, while others found it took time to recover, accepting they would always miss their parents.24 28 Children in the studies reported the support they received did not match their needs and quickly dwindled28 and their loss was soon forgotten by others.28 Children missed being asked how they were and needed to know that people still cared.28 Children felt teachers lacked awareness, resulting in insensitive and unintentional hurtful comments or situations.23 28 31 However, some described teachers' understanding of grief and ongoing support in remembering birthdays and anniversaries.28 31 Such children highlighted the school as a good source of support, a safe place, providing a sense of belonging, routine and emotional escape through extracurricular activities.24 25 28 31

Children did not always understand the sources of support, and their perceptions of who should or could support them varied, including parents,27 31 themselves or friends.27 Professional support, although mentioned infrequently, was described as helpful. Children described professional support from counsellors, psychologists and the healthcare professionals caring for their parent.24 30 31 Professionals were seen as helpful when they were being honest with them, checking on their well-being, helping them develop coping strategies, being open and flexible to their needs, and being available quickly.24 30 31 Although children wanted professionals to converse with them, it was important that they were not forced to talk.30 Some children appeared unaware of professionals as a source of support.30

The most helpful types of support came from people who were well known to children before their loss.23–25 27 28 30 31 Friends knowing the deceased parent provided special conversational support, as it was easier to talk to them and share memories.27 Children also felt more secure speaking with close friends, with less worry of being teased or hurt.27

Distraction with friends helped children cope by offering a temporary escape and emotional release.27 29 31 Usual routines provided security and stability, explaining why many children wanted to return to school soon after their loss.25 29 31

Continuing a relationship with their deceased parent provided comfort and helped children cope.23–25 29–32 Relationships were maintained using mementoes to keep their parent’s legacy and memory alive,29 31 and speaking to the deceased in the present, letting them know what was happening in their lives, and asking for advice or protection provided comfort, stability, unity and a sense of belonging.23 25 29 32 Some children hid these conversations as they did not want to make others upset or were from a culture where discussing death was discouraged.23 Remembering them together with happy and positive memories, avoiding talking about sad or scary times that made them feel sad or distressed,32 or having an image of the deceased helped some feel more whole, filling the void their parent left.23

Some children were comforted and supported by their faith and belief in an afterlife, sensing God’s presence helping them overcome their problems.24 25 29 30 In contrast, other children lost faith, felt angry and blamed God.24 26 29 Some of the children who initially lost faith found later that their faith did help them overcome the trauma, and they subsequently felt a stronger relationship with God.24

Adjusting as a surviving parent

Review findings showed that parents lost their 'normal' lives, family dynamics changes and they were forced into life as single parents.32–37 Parents felt heavy demands on their time and mental resources, struggling to share their time between their children, which often led to arguments and misunderstandings.32 33 Other parents had too much time, leaving them feeling alone, frustrated and craving companionship.33 35 36 Fathers' jobs were often incompatible with childcare, meaning some changed working hours, jobs or stopped work altogether.33 35 Some parents found that previous social networks disappeared altogether. They were treated differently by friends, with one common explanation being that friends felt uncomfortable.34 35 37 These reactions were unexpected, leaving parents feeling abandoned and let down.34 37 Not all parents had this experience; some had continued and sustained support from friends.34 37

While adjusting to new parental roles and family life, parents were grieving themselves. It was challenging and took time to accept their loss and address their new realities.33 34 36 Parents had sole responsibility for their children, which was often daunting and scary; parents felt alone, helpless and vulnerable, struggling to make decisions.33–37 Parents worried about what was best for their children. Some questioned most decisions they made for fear of getting it wrong; some turned to extended family or others for advice.35 36

Parents considered their mortality and re-evaluated how they lived, prioritising their children.33 35 Parents often feared future relationships, worrying about children’s reactions, if a new partner would accept the role of the deceased within the family and the chance of losing someone again.33 34 Despite this, parents spoke of missing companionship and wanted their family to feel whole; some were open to new relationships.33–35 Parents reflected on the future they had lost, including loss of hopes and dreams, growing old together, being a 'traditional' family, and feeling sad that the children had lost a parent.34

Parenting alone was stressful,35 undertaking roles and responsibilities previously filled by the deceased. Some struggled with becoming the primary caregiver and disciplinarian, and providing emotional support.32–36 Some mothers noticed their sons assuming the father role, some stopped this, while others actively encouraged their son to be like their father.36 Fathers in one study spoke of newfound respect for their partners; having taken on their roles, they felt regret that they had not appreciated them more.35 Parents in several studies reported their children took on more responsibilities, helping around the house and caring for siblings.32 36

Parents' acceptability, availability and engagement with support

As with the children, parents received immediate support from family, friends, community, and their faith-based community, offering help and practical support.34 36 37 Initially, it was common for parents to struggle to accept support, even when needed and beneficial.32 33 35–37 Trying to show others they could cope, asking for help was a weakness, making some feel ashamed.32 34 However, fathers in one study were more accepting of support, acknowledging they could not manage without help.35

Parents in several studies found flexibility and understanding from their workplace and networks to be helpful, as these allowed them to be available for their children while still financially supporting their families.31–33 35 36

Some parents struggled finding appropriate professional bereavement support, reporting a mismatch between needs and help provided, with some professionals not equipped to deal with their needs or situation.33 37 Parents desired more professional help and information both prebereavement and postbereavement.30 33 In particular parents wanted professionals to be honest, deliver information which the family could handle, and show concern for the families individual needs.30 Some parents needed reassurance and would have liked a professional to check in on their family to ensure they were coping adaptively and provide information about their options, practical help and guidance on supporting the family.33 Some parents found others expected them to seek professional support, and if they chose not to, this was questioned.33 Parents had mixed experiences with school support, with some appreciating the tremendous support they received from teachers.31 35 36 Others found a lack of communication and understanding at school.31 School support was not mentioned by a study with widowed fathers in Denmark,33 despite those schools having bereavement response plans.22

Like the children, many parents experience dwindling support and a belief that they must cope with their loss alone and not burden others.31 33 36 37 Parents desired continued and sustained support from those within their networks and the professionals around them.31 33 36 37 It was important to have people around them who cared. However, some parents found that friends were unable or unwilling to provide the support they anticipated.34 People did not always know how to support them, causing offence rather than comfort.37

Faith helped some parents, receiving a positive response from the church community,34 who provided support, sympathy, advice, and practical and financial help.33 35 36 Some parents found praying helped bring them closer to God.34 However, not all parents found their faith helpful; some felt anger towards God, feeling let down and questioned if there was a God.34

Like the children, parents found those with a shared loss experience to be most supportive. Parents actively sought out bereaved peers and peer support groups who understood and could relate, sharing similar struggles and feelings, normalising their own experiences, and helping them adapt to their new lives and the challenges they faced.31 33–37 With these peers, they could be vulnerable; did not feel a burden and saw hope for the future, realising that grief was time-limited.33 36

Supporting the children

For many parents, their children brought meaning to their lives, a reason to carry on, and they focused on putting the children first.33 35–37 At times, this came at a cost, leaving parents with no time for themselves.35

Parents seldom asked children about their needs and used their judgements to handle situations, with some unaware of the support children received from teachers and siblings.30 36 Others misunderstood their child’s reactions and believed denial, disbelief and shock to be signs that the child did not understand and were not in mourning.36 Even when parents saw changes, they often felt ill-equipped to deal with changes and support their children.36

Many parents described difficulties breaking news of the death.36 37 Some felt guilty for not preparing the children for the death.31 Some were in denial; others felt the children’s lives would be affected soon enough, so why do that sooner.31 Those who talked to their children gave comfort and support and were open with their own emotions, finding this led to less conflict in the family.32 However, not all families could have open and honest communication, and some parents did not speak to their children or put effort into hiding their emotions to protect one another.36

Carrying on a relationship with the deceased was important to ensure children remembered them. Parents created memory boxes, and shared memories and stories of the deceased, bringing them into everyday life.32 34 36 Parents noticed that they chose to remember the good memories.32 However, not all parents were sure how or if they should continue a relationship with the deceased.34 When talking about the deceased, many waited for the children to initiate conversations and then seized the opportunity to ask how they were feeling.32 Some parents noticed that their children stopped talking or asking questions about the deceased when they saw it upset them.36 Others believed children avoided the conversations as it made them sad.32 Some forced themselves to talk and show emotions so their children knew it was OK to remember.36

Parents in many studies suppressed their emotions and grief to protect their children,33 36 37 which made them feel lonely.36 If parents were advised to be open with their children’s emotions, they saw the benefits for the family and how doing so could bring the family closer.36 Parents also noticed their children modified their behaviours and took on more responsibilities to protect them, and some were reliant on their children’s support.32 36 Parents in one study noticed their children worried for them, and for some, a role reversal could be seen.36 Children were worried about losing the surviving parent, which sometimes led to 'clingy' behaviour, worry, anxiety and distress.36