Prolonged grief disorder in bereaved parents: Exploring impacts and treatment pathways

Abstract

Prolonged grief disorder (PGD) is characterized by intense and persistent grief that significantly impairs daily functioning. For bereaved parents, the loss of a child represents an unparalleled emotional challenge, placing them at heightened risk of developing PGD. This review traces the evolution of PGD from early conceptualization to current definitions in the International Classification of Diseases, 11^th revision, and Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition, Text Revision. Building on this historical foundation, the analysis examined the prevalence, risk factors, and diagnostic criteria of PGD in bereaved parents, with particular attention to sex differences, the nature of the loss, and the time elapsed since the child’s death. Furthermore, this review examines the multidimensional consequences of PGD on parents, including its emotional, physiological, and functional effects. Evidence-based treatments for PGD, such as psychotherapeutic approaches and emerging interventions, are also discussed. By synthesizing existing research, this review provides a comprehensive understanding of PGD among bereaved parents, highlights the unique challenges they face, and offers practical insights and recommendations for clinicians working with this population.

Key Words: Prolonged grief disorder; Parental bereavement; Child loss; Diagnostic and Statistical Manual of Mental Disorders; Mental health

Core Tip: Prolonged grief disorder (PGD) is a persistent and debilitating grief response that disproportionately affects bereaved parents. This minireview examines PGD’s prevalence, risk factors, and consequences, focusing on sex differences, cultural influences, and family dynamics. It highlights diagnostic complexities related to International Classification of Diseases, 11^th revision, and Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition, Text Revision criteria, as well as challenges in distinguishing PGD from normal grief, depression, and post-traumatic stress disorder. The review further evaluates evidence-based treatments, including cognitive-behavioral therapy and emerging interventions, offering critical insights for clinicians and researchers working to improve support for bereaved parents.

INTRODUCTION

Prolonged grief disorder (PGD) is a condition characterized by intense, persistent grief lasting beyond normative periods and is now formally included in the leading diagnostic systems of the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition, Text Revision (DSM-5-TR)[1] and International Classification of Diseases, 11^th revision (ICD-11)[2] (Table 1). Bereaved parents face heightened vulnerability to PGD due to the distinctive nature of such a loss, often leading to substantial personal and familial consequences. PGD is a common phenomenon among bereaved parents (whose rate may exceed 45% in vulnerable groups)[3,4], and its prevalence varies by parental sex, age, economic condition, and the traumatic nature of the child’s death[5,6]. The prevalence of PGD varies significantly across studies due to methodological differences, cultural factors, and sample characteristics. When affecting parents, the disorder in question is often associated with significant personal mental health impairments such as depression and post-traumatic stress disorder (PTSD), while its salient manifestation in the familial context is spousal disruption and maladaptive parenting[7]. Furthermore, PGD is difficult because of its overlap with normal grief, which varies across individuals and cultures. While the ICD-11 and DSM-5-TR[1,2] provide timelines (6 and 12 months, respectively), they may not explain all variations, which might increase the risk of misdiagnosis. PGD symptoms also overlap with depression and PTSD, further complicating diagnosis[8]. Cultural differences significantly shape grief expression and coping mechanisms. Some cultures may exhibit prolonged grief reactions due to social expectations, stigma, or limited mental health resources[5,6]. PGD represents a critical challenge in mental health; however, its diverse impacts, particularly among bereaved parents, remain insufficiently examined.

Table 1 Diagnostic criteria for prolonged grief disorder in International Classification of Diseases, 11^th revision, and Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition, Text Revision.

Criterion	ICD-11	DSM-5-TR
Event criterion	Experience of bereavement due to the death of a significant other, such as a partner, parent, or child	Death of a close individual at least 12 months prior (or 6 months for children/adolescents)
Core symptoms	Persistent grief response marked by either longing for the deceased, or preoccupation with the deceased	Grief response with one or both of the following: Intense yearning/longing for the deceased, or preoccupation with thoughts or memories of the deceased
Emotional distress	Intense emotional distress including sadness, anger, guilt, or difficulty finding meaning in life	At least three symptoms from a set including identity disruption, disbelief, emotional numbness, and intense loneliness, occurring most days for over a month
Functional impairment	The grief response leads to substantial difficulties in personal, social, or occupational functioning	Symptoms cause clinically significant distress or impairment in daily functioning
Cultural context	Symptoms persist beyond what is culturally or socially expected for the individual’s context	The intensity and duration of grief surpass culturally accepted norms for bereavement
Differentiation	Symptoms must not be better explained by other mental health conditions, substance use, or medical issues	Grief-related disturbance cannot be attributed to another psychological or medical condition

DSM-5-TR: Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition, Text Revision; ICD-11: International Classification of Diseases, 11^th revision.

This review addresses key issues by exploring the historical evolution of the clinical concept of PGD, its prevalence, risk factors, and profound personal and familial consequences. Additionally, it highlights the diagnostic complexities, need for culturally adapted approaches, and limitations of existing therapeutic strategies. This work can contribute to academic and clinical discourse by offering a comprehensive understanding of the phenomenon in question, while providing directions for future research and intervention development. This minireview synthesizes recent literature exploring the conceptual and diagnostic evolution, prevalence, risk factors, associated outcomes, and interventions for PGD in bereaved parents, focusing on evidence from quantitative and qualitative studies predominantly conducted within the last two decades.

HISTORICAL AND CONCEPTUAL EVOLUTION OF PGD

Losing a loved one is a profoundly painful yet universal human experience[9]. For most individuals, the grieving process unfolds naturally, and the intensity of emotional distress gradually diminishes over time[10]. However, a significant minority experience a grief response that remains abnormally persistent, resulting in severe emotional pain and functional impairment[11]. The term “complicated grief” has evolved significantly over time, reflecting ongoing research and refinement in the understanding of pathological grief responses[12]. Initially, in 1993, the concept was introduced by Horowitz and colleagues as "pathological grief", emphasizing the persistent and disabling emotional distress associated with loss[13]. Subsequent research has broadened the understanding of this phenomenon, leading to various terms such as "traumatic grief", "prolonged grief", and "complicated grief", which highlights the complexity of the condition beyond mere persistence[9,14]. Eventually, this condition, termed pathological or prolonged grief, has been classified in recent diagnostic frameworks under different terminologies, including PGD in ICD-11 and persistent complex bereavement disorder (PCBD) in DSM-5-TR[8].

Both the ICD-11 (World Health Organization, 2018)[2] and the DSM-5-TR (American Psychiatric Association, 2022)[1] aim to differentiate normal grief processes from pathological forms; however, their criteria reflect slightly different emphases. These frameworks recognize pathological grief as a distinct clinical entity with overlapping features but nuanced differences in definitions and diagnostic requirements[15]. The ICD-11 defines PGD as a persistent and pervasive grief response following the death of a close individual, such as a partner, parent, child, or other significant person[2]. The core features are prolonged longing or persistent preoccupation with the deceased, accompanied by intense emotional pain, including sadness, guilt, anger, denial, blame, difficulty accepting the death, a sense of losing part of oneself, emotional numbness, or inability to experience positive emotions. These symptoms often disrupt an individual’s ability to engage in social or other activities[2]. The ICD-11 requires these symptoms to persist for over 6 months and exceed the expected norms for the individual’s cultural, social, or religious context. While extended grieving consistent with cultural or religious practices is not considered pathological, a PGD diagnosis necessitates significant impairment of personal, social, or occupational functioning[2].

The DSM-5-TR defines PCBD as a condition marked by a prolonged and intense response to the death of a close individual[1]. The diagnostic criteria include at least one core symptom: Persistent yearning, intense sorrow, preoccupation with the deceased or death occurring most days for at least 12 months[1]. Additionally, at least six supplementary symptoms must be present: Difficulty accepting death, emotional numbness, anger, maladaptive self-appraisals (e.g., self-blame), avoidance of reminders, a desire to reunite with the deceased, trust difficulties, feelings of isolation, perceptions of life as meaningless, identity confusion, and difficulty pursuing future goals[1]. For a PCBD diagnosis, these symptoms must persist for at least 12 months, result in significant distress or impairment of functioning, and be disproportionate to the cultural or religious norms of grief and bereavement. Both frameworks focus on the persistence, pervasiveness, and impact of grief symptoms[16]. The ICD-11 sets a shorter time frame of 6 months for PGD, reflecting a broader cultural and contextual sensitivity, while the DSM-5-TR emphasizes a longer duration of 12 months and incorporates a more detailed symptomatology[16,17]. Despite these differences, both frameworks acknowledge the profound emotional, social, and functional toll of pathological grief, distinguishing it from typical bereavement processes[18].

The temporal criteria divergence between ICD-11 (6 months) and DSM-5-TR (12 months) presents significant implications for PGD diagnosis and research[8,16]. Recent studies demonstrate that these different timeframes affect prevalence rates and diagnostic classifications[18]. Haneveld et al[16] found that while the diagnostic systems show substantial overlap in core symptoms, the temporal differences influence how grief trajectories are evaluated. This variation is particularly relevant in cross-cultural contexts, as Killikelly and Maercker[19] emphasize that cultural norms significantly impact grief expression timeframes. Additionally, Treml et al[18] note that these diagnostic variations complicate cross-cultural research comparison and epidemiological studies. The temporal criteria differences also affect clinical practice, as highlighted by Eisma[8], potentially influencing treatment initiation timing and creating challenges in establishing consistent diagnostic approaches across different healthcare systems.

Diagnosing PGD is challenging because of the need to distinguish it from normal grief, which varies widely between individuals and cultures[20]. The timelines set by the ICD-11 (6 months) and DSM-5-TR (12 months) provide guidance but may not fully capture this variability, risking misdiagnosis or overdiagnosis[21]. Additionally, PGD symptoms overlap with conditions such as depression and PTSD, complicating differential diagnosis[8]. The subjective nature of grief symptoms, such as longing and emotional pain, further adds to the complexity, as they rely heavily on self-reporting and clinician interpretation, without clear biological markers[19]. Cultural and social factors also play a significant role, as the norms surrounding mourning practices differ globally, potentially leading to culturally insensitive diagnoses[19,22]. Furthermore, the medicalization of grief has sparked debate, with concerns about pathologizing universal experiences and stigmatizing individuals[23,24]. Addressing these challenges requires cultural competence, standardized diagnostic tools, and public education to reduce stigma, along with continued research to refine diagnostic criteria and improve clinical interventions (Figure 1)[8,25].

Figure 1 Challenges in diagnosing prolonged grief disorder. PGD: Prolonged grief disorder; PTSD: Post-traumatic stress disorder.

PREVALENCE AND RISK FACTORS IN BEREAVED PARENTS

PGD is significantly prevalent among bereaved parents, with reported rates varying across populations and contexts ranging from approximately 10% to 49% in vulnerable subgroups. For instance, a meta-analysis revealed that 20.9% of Chinese “Shidu” parents (those who have lost their only child) met the criteria for PGD[5,26], whereas a study conducted in the United States among older bereaved parents reported a prevalence of 47.5%[4]. Similarly, in a family-oriented rehabilitation program in Germany, 49.5% of bereaved parents exhibited PGD symptoms[3]. A meta-analysis encompassing 14 studies found somewhat lower rates, indicating that approximately 9.8% of bereaved adults in the United States experienced PGD symptoms[27]. In Sweden, one study reported an even higher prevalence, with 16% of 225 bereaved parents meeting the diagnostic criteria for PGD[28]. These rates were considerably higher than those observed in other bereaved groups, reflecting the distinct psychological burden associated with parental bereavement.

Bereaved parents often exhibit higher rates and more severe symptoms of PGD compared to individuals grieving the loss of other family members, with research suggesting that parental bereavement elicits more intense and persistent grief reactions. Evidence from meta-analysis work indicates that PGD prevalence in bereaved parents might reach 2-3 times higher than in widowed or adult-child bereaved individuals due to the unique, profound nature of losing a child[5]. For example, a population-based study assessed the prevalence of complicated grief among several bereaved groups in a large representative German sample (n = 2520), which included individuals who lost a child, a spouse, and a parent[29]. According to the findings, grief severity and prevalence were highest among bereaved parents, with a complicated grief prevalence of approximately 24% among the latter, significantly exceeding the rates in other bereaved groups.

Several factors might contribute to this increased vulnerability in cases of the loss of a child in bereaved parents, particularly the violation of the natural life course and the heightened self-blame, guilt, and identity disruption, as their parental role is central to self-concept and daily functioning[3,30]. Additionally, the familial consequences of child loss, such as increased marital discord and negative parenting effects on surviving children (as discussed in depth in the next chapter) might complicate grief severity[7], whereas sibling or parent loss in adult offspring typically lacks such systemic ramifications. The loss of a child represents not only the death of a loved one but also a profound disruption to parental identity and role fulfillment. Parents’ psychological investment in their children often forms a core component of their self-concept and life purpose[7,30]. This unique aspect of child loss may partially explain the heightened vulnerability to PGD among bereaved parents, as they struggle not only with grief but also with the reconstruction of their identity and purpose[31,32]. The loss challenges parents' fundamental assumptions about their protective role and can shatter their sense of meaning and continuity[30,32]. This understanding helps explain why parental bereavement often manifests in prolonged and intense grief reactions that may meet PGD criteria.

Risk factors for PGD indicate that mothers are at significantly higher risk compared to fathers. A recent meta-analysis found that mothers are nearly twice as likely to meet the diagnostic criteria for PGD[5], while other studies reported higher rates of depression, PTSD, and complicated grief among mothers than among fathers[3,33]. Sex-related factors play a significant role in grief severity and its duration. This gap between mothers and fathers can be attributed to differences in emotional processing, caregiving identity, and societal expectations. Mothers are more likely to experience intensified grief due to stronger emotional bonds and distinct parenting style and involvement in child-rearing[34], which leads to heightened distress when this role is disrupted[3,4]. Additionally, sex norms influence grief expression, where fathers may be socially reinforced to suppress emotional responses, leading to lower reported grief symptoms (but potentially more internalized distress), whereas mothers are more likely to express and seek support for their grief[5,33]. The integration of these psychological vulnerabilities and sex-related grief dynamics underscores why PGD can persist more prominently in bereaved mothers and why sex-sensitive interventions may be necessary to address their specific needs.

Additional demographic and situational risk factors include advanced parental age, shorter time since loss, poor economic conditions, lower levels of parental education, and the traumatic nature of the child’s death (e.g., accidents or suicides)[6,26,27]. Psychological and relational factors also contribute to risk. Avoidant coping strategies, fearful attachment styles, and low perceived social support are linked to greater grief severity, while protective factors such as strong spousal relationships, spiritual engagement, and meaning-making help mitigate symptoms and promote resilience[4,6,30]. Psychologically, maladaptive coping mechanisms, such as avoidance tendencies and fearful attachment styles, have been consistently linked to increased grief persistence. Parents who rely on avoidant coping strategies experience heightened difficulty in processing their loss, which reinforces emotional pain and intensifies symptoms over time[4,6]. Insecure attachment, characterized by heightened anxiety and avoidance in relationships (i.e., attachment anxiety, attachment avoidance), further complicates grief by disrupting the ability to seek social support after a child’s loss[4,30,35]. Within marital settings, grief misalignment between partners (e.g., where one parent internalizes distress while the other seeks emotional expression) often leads to interpersonal strain, miscommunication, or withdrawal, increasing the likelihood of relational breakdown[3,6]. While much research focuses on specific cultural groups, such as “Shidu” parents in China, further studies are needed to examine wider populations, especially western ones. Furthermore, the interaction between risk factors for PGD in bereaved parents remains insufficiently explored. While individual factors such as female sex, advanced parental age, unnatural causes of loss, and poor socioeconomic status have been identified as significant contributors to PGD severity[4-6,26], their potential interaction effects remain unclear. For instance, poverty and low education levels could exacerbate PGD by limiting access to mental health resources, but how these socioeconomic constraints interact with sex or age-related susceptibility has not been profoundly examined. Although studies confirm that mothers are at higher risk than fathers[3,5,6], researchers have yet to determine whether this sex disparity is further amplified by financial insecurity or differences in parenting characteristics and coping mechanisms. Additionally, while advanced parental age has been linked to increased PGD severity, especially in Shidu parents[5,26], it is uncertain whether this effect stems from biological vulnerability, reduced social support, or financial limitations following the loss of an only child. Given these gaps, future research should systematically investigate how overlapping demographic and socioeconomic risk factors interact to shape PGD outcomes in bereaved parents.

CONSEQUENCES OF PGD IN BEREAVED PARENTS

PGD in bereaved parents is associated with significant personal mental health impairments such as depression and cognitive changes, as well as familial dysfunction, including spousal discord and maladaptive parenting. Recent studies indicate that most parents with PGD experience overlapping mental health conditions, particularly PTSD, depression, intense psychological distress, and anxiety disorders[3,36,37]. Beyond the profound impact on mental health, parents who have lost a child often exhibit significant physical and social impairments, including chronic diseases and higher rates of substance and alcohol abuse, particularly when grief remains unresolved[38-40]. Bereaved parents face unique vulnerabilities owing to the profound nature of their loss. PGD significantly disrupts family dynamics and affects spousal relationships, parenting, and the psychological well-being of surviving children. Divergent grief trajectories and maladaptive coping strategies such as avoidance or withdrawal often led to marital conflict and emotional distance. However, supportive dynamics like open communication and shared meaning-making can help mitigate these challenges[41-44].

PGD also disproportionately impairs parent-child relationships. Parents with PGD often exhibit reduced emotional availability, leading to heightened emotional and behavioral difficulties in surviving children. Maladaptive parenting styles, including overprotection, harsh discipline, and emotional neglect, hinder children’s developmental needs and psychological wellbeing[31,32,45]. Surviving children frequently experience significant distress, including symptoms of anxiety, depression, and grief compounded by their parents’ emotional unavailability and unresolved grief[46,47]. Bereaved parents who lose a child often struggle with persistent emotional dysregulation and parenting difficulties, marked by emotional numbness and preoccupation with the deceased child. Their intense, prolonged grief can lead to emotional withdrawal, disrupting connections with surviving children[7,31]. This conflict between grief and parenting responsibilities results in inconsistent caregiving behaviors, with parents shifting between emotional detachment and over-involvement[7,46,47]. Some parents with PGD exhibit heightened fear of further loss, leading to overprotection of surviving children[47], while others withdraw, fostering neglect or alienation[38]. In such cases, role reversals (i.e. parentification) may occur, with surviving children playing a role of emotional caregiving for their grieving parents[7,46].

Emerging evidence suggests that parental PGD may have intergenerational consequences. A study by Lenferink and O’Connor[48] found that changes in PGD symptoms in bereaved parents significantly predicted grief-related outcomes in their adult children. Shared bereavement may amplify grief symptoms in children, particularly in contexts such as sibling loss, as children model the emotional dysregulation observed in grieving parents[31,49]. To avoid distress, some parents refrain from discussing the deceased child, leaving surviving children to grieve alone[46,49]. Conversely, others display excessive grief, burdening their children emotionally. This hyperfocus on the deceased through rituals, idealization, or stagnation in parental identity, can distress surviving children, making them feel inadequate in comparison to their deceased sibling[7,46].

Research conducted primarily in Asian populations reveals that during periods of prolonged grief, bereaved parents may exhibit permissive or neglectful parenting styles toward their surviving children, largely due to their emotional and physical unavailability[32,46]. Surviving siblings often experience feelings of neglect or resentment as parents struggle to balance the demands of grieving and caregiving[38,32]. This dynamic, commonly characterized as the conflicting demands of parenting and grieving, underscores the profound impact of PGD on family relationships and the attachment security of children[7,35]. When a child’s prolonged illness precedes death, surviving siblings may face even greater challenges, including heightened feelings of neglect due to their parents’ preoccupation with caregiving responsibilities. Such circumstances can intensify the emotional strain on surviving children and further destabilize family dynamics[45]. Therefore, certain circumstances surrounding bereavement may intensify the effect of parental PGD on surviving children. These factors can further complicate a child’s ability to navigate and adapt to their parents’ enduring grief, particularly within the complicated dynamics of family relationships. Unlike normative grief, which eases over time, PGD intensifies disruptions in parental functioning even years after the loss[33,50]. As a result, the children of bereaved parents with PGD face a higher risk of maladaptive grief, emotional dysregulation, and attachment difficulties[46,49].

PGD INTERVENTIONS AND SUPPORT FOR BEREAVED PARENTS

Evidence-based cognitive-behavioral therapy (CBT) for PGD involves constructing a coherent and meaningful personal narrative around the loss, addressing and reframing negative beliefs about oneself, the world, and the future, and gradually confronting avoided grief triggers, such as specific locations, memories, or possessions[14,51]. This therapeutic approach encourages setting new life objectives and engaging in purposeful activities to foster recovery[52,53]. While CBT demonstrates efficacy in treating PGD[51,52], several sociocultural and economic factors influence treatment implementation and outcomes. The recommended treatment duration typically ranges from 12-16 weeks[54-56], with session frequency varying based on symptom severity and individual needs. Treatment effectiveness can be moderated by therapist expertise in grief-specific interventions[57], cultural competency[19], and socioeconomic circumstances. Financial constraints often limit access to mental health services[38,39], particularly affecting vulnerable populations such as Chinese “Shidu” parents[26,42]. Studies indicate that cultural adaptations of CBT protocols are essential, as mourning practices and expressions of grief vary significantly across cultures[19,22]. Additionally, the availability and integration of social support networks can significantly impact treatment outcomes, highlighting the need for comprehensive intervention approaches that consider both cultural and socioeconomic contexts[57].

Despite the profound psychological impact of losing a child, a notable gap remains in rigorously evaluated psychosocial interventions specifically designed for bereaved parents[54]. Nevertheless, CBT has consistently demonstrated efficacy in addressing symptoms of prolonged grief, whether delivered in-person[55,56] or through internet-based platforms[58,59]. Empirical studies have demonstrated the effectiveness of CBT-based interventions[60,61]. In one study examining bereaved parents with PGD, researchers evaluated a CBT-based app used for over 1 month. The application focuses on three tasks: Confronting loss, rebuilding confidence, and engaging in adaptive activities. Significant reductions in grief symptoms, rumination, avoidance, and negative cognition were observed post-assessment[60]. In a longitudinal study with follow-up assessment, bereaved parents, 6 months to 6 years after losing a child with cancer, participated in a 16-week cognitive-behavioral-existential intervention. The program improved prolonged grief, meaning, depression, hopelessness, continuing bonds, post-traumatic growth, positive affect, and quality of life. Most gains persisted or increased at the 3-month follow-up[61].

Emerging innovative approaches show promise in addressing treatment barriers and expanding access to PGD care. Digital health interventions, including mobile applications and teletherapy platforms, offer scalable solutions that can reach underserved populations and overcome geographical constraints[58-60]. These technologies enable personalized treatment delivery through algorithm-based symptom monitoring and adaptive intervention protocols[54,57]. Additionally, hybrid care models that combine professional treatment with peer support networks and community resources may enhance treatment effectiveness and sustainability. Future directions point toward integrative approaches that synthesize multiple therapeutic modalities, potentially incorporating mindfulness-based techniques, creative arts therapies, and trauma-informed practices. The development of precision medicine approaches, tailoring interventions based on individual grief trajectories and risk factors, represents another frontier in PGD treatment innovation. In addition to individual therapeutic approaches, some countries have also developed comprehensive treatment programs. In Germany, family-oriented rehabilitation programs provide medical and multimodal psychosocial interventions for bereaved parents in inpatient clinics[3]. This program supports parents in coping with the loss of a child through a comprehensive 4-week residential stay, incorporating both group and individual therapy.

Despite the availability of such tailored programs, significant barriers impede bereaved parents’ access to treatment. Financial constraints, limited availability of specialized therapists, and logistical challenges such as childcare and transportation restrict access to treatment[16]. The inadequate training of mental health professionals in grief-specific interventions further compounded these issues[57]. Stigma associated with mental health and grief may discourage parents from seeking assistance, while self-stigmatization and societal misconceptions regarding grief exacerbate these barriers, frequently resulting in delayed intervention[23]. Additionally, cultural norms and variations in mourning practices may contribute to misdiagnosis or culturally insensitive care, highlighting the need for culturally adapted interventions[19]. Cultural variations significantly influence the manifestation and treatment of PGD[19,22]. For instance, in many Asian societies, prolonged expressions of grief receive greater social acceptance and may even be culturally prescribed, particularly in the context of losing a child[26,42]. This cultural sanctioning of extended mourning periods can complicate the application of standardized diagnostic criteria[19]. Therapeutic approaches must therefore be calibrated to align with cultural grief expressions and healing practices[19,22]. While Western-developed interventions emphasize individual processing and adaptive coping, collectivist societies may benefit more from family-centered or community-based healing approaches that honor cultural traditions and values[22]. This cultural heterogeneity in grief expression and acceptance necessitates flexible diagnostic frameworks and culturally-informed therapeutic strategies[19].

Current systematic reviews highlight the importance of addressing bereaved parents’ needs by preparing them for loss, offering a sense of control[62], and creating opportunities to say goodbye and grieve in alignment with their beliefs and circumstances[63]. A comprehensive meta-analysis of 52 studies involving approximately 4000 bereaved parents further emphasized the importance of healthcare support[64]. Parents value the opportunity to say goodbye to their children in the hospital and express regret when this possibility is not provided. Clear and detailed information about their child's death is essential because withholding information can cause significant frustration. Although autopsy results often pose challenges, even when consent is provided, follow-up appointments help parents process information and address delayed questions. Ongoing emotional support from healthcare professionals significantly aids in coping processes[64]. Although accompanying parents during their child's terminal phase and providing continued bereavement support are essential, research indicates that such support is not consistently available (Figure 2)[57].

Figure 2 Recommendations for healthcare providers supporting bereaved parents.

DISCUSSION

PGD is a notably prevalent phenomenon among bereaved parents, and its rates are considerably higher than those in other bereaved groups. Despite reported rates varying by population and context, the findings in the literature reflect the unique psychological burden of parental bereavement. These findings underscore the significant and multifaceted consequences of PGD in bereaved parents, particularly those who have lost a child[3,7,31,45]. This condition is marked by profound mental health challenges, including depression, anxiety, PTSD, and elevated risks of physical comorbidities such as chronic illnesses and substance abuse[3,38]. Familial impacts are equally substantial, with PGD disrupting spousal relationships and impairing parental roles, often leading to relational tensions and adverse outcomes for surviving children[42,48]. These effects highlight the need to address PGD’s far-reaching consequences in both the clinical and familial contexts. The challenges faced by bereaved parents with PGD stem from the intensity and uniqueness of parental loss. PGD undermines interpersonal dynamics by straining spousal connections through divergent grief trajectories and misaligned coping mechanisms[42]. It also significantly disrupts parent-child relationships, as derived from reduced emotional availability, overprotectiveness, or neglect, which adversely affect the psychological well-being of surviving children[31,32]. Moreover, the potential for intergenerational transmission of grief symptoms underscores the implications of unresolved PGD within families[48].

IMPLICATIONS FOR PRACTICE AND RESEARCH

Clinicians should adopt a holistic approach to diagnose and treat PGD in bereaved parents, considering not only individual symptoms but also broader familial and cultural contexts. In addition to the broader clinical implications, addressing PGD among bereaved parents underscores the vital role of mental health and educational professionals. School counsellors, educators, and other frontline workers in educational settings often respond first to familial grief, particularly in cases involving surviving children. As highlighted in the literature, these professionals frequently experience emotional strain and face challenges in providing adequate support due to limited training and resources[65,66]. Integrating grief-specific training into professional development for educators and mental health practitioners could enhance their capacity to support grieving families effectively while also addressing their own emotional well-being. Such measures would help bridge gaps in systemic support and foster resilience within bereaved families and educational communities[65,67].

Interventions should focus on strengthening spousal relationships, promoting effective grief communication, and providing parenting support to mitigate the impact of grief on surviving children[41,35]. Culturally sensitive tools and frameworks should be developed to address the unique needs of diverse populations. Future research should prioritize longitudinal studies to explore the long-term trajectories of PGD among bereaved parents and their families. Additionally, investigating the efficacy of targeted interventions in mitigating the psychological and relational consequences of PGD will provide valuable insights into the best practices for clinical care.

LIMITATIONS

This article provides valuable insights into the prevalence, risk factors, and consequences of PGD among bereaved parents. However, several limitations should be noted. First, while this mini review synthesizes current evidence, the format necessarily limits the comprehensiveness and depth of analysis possible. Second, much of the literature reviewed focuses on specific cultural contexts, which limits the generalizability of findings to Western or other diverse cultural settings, especially given that cultures differ significantly in their death perceptions, mourning practices, and family structures[19,22]. Third, the review predominantly included cross-sectional and retrospective studies, which provide a snapshot of PGD but fail to capture its long-term progression or intergenerational effects. This methodological limitation makes it particularly difficult to clarify the temporal evolution of PGD symptoms over years or decades, and their dynamic impact on family relationships, including parent-child and spousal interactions[7,45]. Fourth, while sex differences in PGD risk are discussed, the interaction of socioeconomic factors, such as poverty or access to healthcare, remains underexplored despite their potential to significantly influence grief experiences. Addressing these limitations in future research through longitudinal designs and culturally diverse sampling could provide a more comprehensive understanding of PGD and its implications for bereaved parents across different populations.

CONCLUSION

This theoretical review comprehensively examined PGD among bereaved parents, focusing on its prevalence, risk factors, and significant consequences. PGD is characterized as a pervasive condition with profound psychological, emotional, and relational impacts, including an increased risk of depression, PTSD, and disruptions in family dynamics. This review outlines the evolution of PGD diagnostic frameworks in the ICD-11 and DSM-5-TR[1,2], emphasizing the challenges in distinguishing pathological grief from normal grieving. This highlights the importance of culturally sensitive diagnostic approaches and interventions tailored to the specific needs of the bereaved parents. Additionally, this review discusses evidence-based therapeutic strategies, such as CBT and family-oriented rehabilitation programs, while addressing barriers to care, including stigma and limited access. By synthesizing recent findings, this review provides valuable insights into the complexities of PGD and offers directions for future research and clinical practice.