Table I.

Summary of Included Studies

Study	Population (n= )	Comparison Group (n= )	Study Design	Follow-Up	Measured Outcome (Instrument); All by self-report	Results
Birenbaum et al. [12]	Bereaved parents (n = 80; 47 mothers, 33 fathers)	Normative adult data (n = 395; 295 women, 100 men)	Longitudinal	2 weeks, 4- and 12-months after child’s death	General health status (Duke-UNC Health Profile);	Bereaved parents’ health did not differ significantly from a normative group of adults on the emotional and symptoms scales. Bereaved mothers’ social health was significantly lower than that of the normal group.
Drew et al. [32]	Bereaved parents whose child received HSCT as part of cancer therapy (n = 28)	Bereaved parents whose child did not receive HSCT (n = 28)	Cross-Sectional	Mean 4.2 years after child’s death (SD not reported)	Depression, Stress and Anxiety (DASS-21); Bereavement Experience (CBI); Prolonged Grief (ICG); Family Function (FAD);	Parents of HSCT recipients reported higher rates of anxiety than parents of children who did not received HSCT (35% versus 25%, respectively). Among parents whose child received HSCT, those whose child died in the hospital had significantly higher ratings for depression, anxiety, and stress. Among parents whose child died in the hospital, grief scores were significantly higher among those whose child received HSCT.
Goodenough et al. [28]	Bereaved parents whose child died in the hospital (n = 20; 10 mother-father dyads)	Bereaved parents whose child died at home (n = 30; 15 mother-father dyads)	Cross-Sectional	Mean 4.4 years after child’s death (SD 2.1 years)	Depression, Stress, and Anxiety (DASS-21); Prolonged Grief (ICG); Family Function (FAD);	For fathers, those whose child died in hospital rather than at home reported significantly higher ratings of depression, anxiety and stress. For mothers, there were no statistically significant differences as a function of place of death. Place of death was not significantly associated with family functioning. Parents whose child died in hospital were significantly more likely to meet criteria for complicated grief.
Jalmsell et al. [31]	Bereaved parents whose child was affected by anxiety during the last month of life (n= 263)	Bereaved parents whose child was not affected by anxiety during the last month of life (n = 137)	Cross-Sectional	4–9 years after child’s death (mean not reported)	Anxiety, depression, psychological well-being and quality of life (VDS);	Bereaved parents whose children were affected by anxiety had greater risks of anxiety (RR 1.6, 95% CI 1.1–2.4); depression (RR 2.0, 95% CI 1.3–3.0), decreased psychological well-being (RR 1.6, 95% CI 1.2–2.0); and decreased quality of life (RR 1.5, 95% CI 1.2–1.8).
Jalmsell et al [33]	Bereaved parents whose child received HSCT as part of cancer therapy (n = 97)	Bereaved parents whose child did not receive HSCT (n = 336)	Cross-Sectional	4–9 years after child’s death (mean not reported)	Anxiety (STAI-T & VDS); Depression (CES-D & Visual Digital Scale); Psychological well-being & Physical health (VDS), Quality of Life (VDS, Goteborg Instrument);	Parents whose child underwent HSCT reported higher rates of anxiety (RR 1.5, 95% CI 1.0–2.1), lower quality of life (RR 1.4, 95% CI 1.2–1.7), poorer psychological well-being (RR 1.3, 95% CI 1.1–1.5) and poorer physical health (RR 1.9; 95% CI 1.1–1.5). Parents whose children had multiple HSCTs (versus one HSCT) had higher rates of anxiety (RR 3.5, 95% CI 1.5–8.2), symptoms of depression (RR 3.4, 95% CI 2.1–5.4), poorer quality of life (RR 1.6, 95% CI 1.4–1.9), poorer psychological well-being (RR 1.5, 95% CI 1.2–1.9) and poorer physical health (RR 1.9, 95% CI 1.4–2.6).
Kreicbergs et al. [20]	Bereaved parents (n = 449; 251 mothers, 191 fathers, 7 unknown)	Non-bereaved parents of well-children, matched by child’s age, sex, and region of residence (n = 457; 266 mothers, 191 fathers)	Cross-Sectional	4–9 years after child’s death (mean not reported)	Anxiety (STAI-T & VDS); Depression (CES-D & VDS); Psychological well-being (VDS), Quality of Life (VDS);	Bereaved parents had increased risks of anxiety based on self-assessment (RR 1.5, 95% CI 1.1–1.9). Bereaved parents had increased risks of depression based on self-assessment (RR 1.4, 95% CI 1.1–1.7) and CES-D (RR 1.4, 95% CI 1.0–2.0). The risk of anxiety and depression was higher in the period 4–6 years after bereavement than in the 7–9 years period. In the 4–6 years period, bereaved parents had greater risk of low psychological well-being (RR 1.4, 95% CI 1.2–1.7) and low quality of life (RR 1.3, 95% CI 1.1–1.5)
Lannen et al. [29]	Bereaved parents with unresolved grief (n = 116)	Bereaved parents who had “worked through” their grief (n = 333)	Cross-Sectional	4–9 years after child’s death (mean not reported)	Anxiety (STAI-T & VDS); Depression (CES-D & VDS); Psychological well-being (VDS), Quality of Life (VDS);	Parents with unresolved grief reported significantly higher rates of anxiety (fathers: RR 4.9, 95% CI 2.2–10.8; mothers RR 3.6, 95% CI 2.0–6.5), depression (fathers: RR 4.3, 95% CI 2.1–8.9; mothers: RR 2.4, 95% CI 1.3–4.2), worsening psychological health (fathers: RR 3.6, 95% CI 2.0–6.4; mothers: RR 2.9, 95% CI 1.9–4.4) and physical health (fathers: RR 2.8, 95% CI 1.8–4.4; mothers: RR 2.3, 95% CI 1.6–3.3). Among parents with unresolved grief: fathers reported significantly higher rates of sleep difficulties (RR 6.7, 95% CI 2.1–17.8); whereas mothers reported significantly higher rates of physician visits (RR 1.7, 95% CI 1.1–2.6), and greater use of sick leave (RR 2.1, 95% CI 1.2–3.5).
McCarthy et al. [13]	Bereaved parents (n = 58; 84% mothers)	None	Cross-Sectional	1.0 –9.8 years after child’s death (mean 4.5 years)	Prolonged Grief (ICG-R); Depression (BDI-II);	10% of bereaved parents fulfilled criteria for prolonged grief disorder; 22% reported clinically significant depressive symptoms Time since death and parent perception of child’s medical care predicted parental grief, but not depression. Perception of child’s quality of life during the last month, preparedness for the child’s death, and economic hardship were associated with both grief and depression.
Moore et al. [11]	Bereaved parents (n = 75; 45 mothers, 30 fathers) representing 58 families	Normative non-patient and psychiatric adult data (n = 1002; 577 women, 425 men)	Cross-Sectional	24-months after child’s death	Current psychological and somatic symptoms (SCL-90);	Bereaved parents’ symptoms (including somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, and hostility) were significantly greater than normal populations, but less than psychiatrically diagnosed outpatients.
Morrow et al. [21]	Bereaved parents (n = 37)	Non-bereaved parents of children with cancer (n = 50; 28 on-therapy; 22 off-therapy)	Cross-Sectional	Not Reported	Psychosocial adjustment (PAIS);	Bereaved parents demonstrated poorer adjustment than non-bereaved parents across all domains including family relationships, domestic environment, health care orientation and social environment.
Norberg et al. [22]	Bereaved parents (n=35, 17 mothers, 18 fathers)	Non-Bereaved parents of children with cancer (n=185, 94 mothers, 91 fathers)	Longitudinal	1 year following child’s death; 1–1.5 years after end-of-therapy for survivors	Post-traumatic stress (PCL-C);	Post-traumatic stress among bereaved parents was positively associated with avoidance at the time of their child’s diagnosis (r= 0.52, p < 0.001) and early in therapy (r= 0.36–0.47, p < 0.05). Avoidance early on during a child’s treatment seemed to be a greater risk factor for post-traumatic stress for bereaved than non-bereaved parents.
Rando [10]	Bereaved parents (n= 54; from 27 married couples)	None	Cross-Sectional	2-months to 3-years after child’s death (mean time not reported)	Individual grief experience (GEI, PEAF);	Parents of children who were ill < 6 months or >18 months had poorer adjustment. Previous loss tended to be associated with poorer outcomes. Anticipatory grief was inversely related to “abnormal” grief responses. Parental bereavement may intensify over time.
Valdimarsdottir et al. [30]	Bereaved parents with short “awareness times” (n = 112 for intellectual, n = 195 for emotional awareness)	Bereaved parents with longer “awareness times” (n = 324 for intellectual, n = 238 for emotional awareness)	Cross-Sectional	Mean 6.4 years after child’s death (SD 1.7 years)	Anxiety (STAI-T & VDS); Depression (CES-D & VDS); Physical Health (VDS), Quality of Life (VDS);	Parents with “intellectual awareness” of child’s impending death < 24 hours were more likely to meet criteria for anxiety (RR 1.7, 95% CI 1.1–2.9) and to report symptoms of depression (RR 1.4, 95% CI 1.1–2.0) Parents with emotional awareness < 24 hours were more likely to report symptoms of anxiety (RR 1.6, 95% CI 1.1–2.2), depression (RR 1.5, 95% CI 1.1–2.0), or poor physical health (RR 1.1, 95% CI 1.0–1.3) Fathers with short awareness times had increased risk of depression (RR 2.1, 95% CI 1.2–3.7) and use of sick leave (RR 8.5, 95% CI 1.1–67.8); Mothers had increased risk of anxiety (RR 2.2, 95% CI 1.2–3.9)

HSCT: Hematopoietic Stem Cell Transplant; DASS-21: Depression, Stress and Anxiety Scale-Short Form; CBI: Core Bereavement Inventory; ICG: Inventory of Complicated Grief; FAD: Family Assessment Device-General Functioning Scale; VDS: Visual Digital Scale; STAI-T: State-Trait Anxiety Inventory; CES-D: Center for Epidemiological Studies Depression Scale; RR: Relative Risk; ICG-R: Inventory of Complicated Grief-Revised; BDI-II: Beck Depression Inventory-Second Edition; SCL-90: Symptom Checklist 90-Revised; PAIS: Psychosocial Adjustment to Illness Scale; PCL-C: Post-Traumatic Stress Disorder Checklist Civilian Version; GEI: Grief Experience Inventory; PEAF: Parental Experience Assessment Form