Sudden or Expected: How the Way a Parent Dies Shapes What Children Need

How a parent dies matters to children, but not in a simple way. Across Nordic population registers, children whose parent died from an accident, violence or another external cause face higher long-term risks than children whose parent died of an illness^[1]. Yet an expected death is not an easy one: many children go into it unprepared, and their distress often begins long before the death^[2].

Some children are told one evening that their mum or dad will not be coming home. Others live for months or years alongside a parent's illness: hospital visits, changes at home, a parent who is there but increasingly unwell. It is easy to assume the first group needs more help. The evidence suggests both need support, at different times and in different forms. This study sets out what research in several countries shows about the difference, and what it implies for the people who support bereaved children.

Registers count "natural" and "unnatural" deaths, not sudden and expected ones

No country routinely records whether a parent's death was expected. Death registers record the cause, and researchers usually split deaths into two groups: natural deaths from diseases and medical conditions, and unnatural deaths from external causes such as accidents, suicide and homicide^[1]. Most unnatural deaths are sudden. But many natural deaths are sudden too, such as a heart attack or a stroke, and registers count them alongside a death after years of cancer treatment. "Unnatural" is close to, but not the same as, sudden.

The split also hides how varied sudden deaths are. In Sweden, a register study covering 1969–2004 counted 44,397 offspring of parents who died by suicide and 41,467 offspring of parents who died in accidents, against 417,365 whose parent died from other causes^[3]. These offspring were of all ages, not only children. In a smaller US clinical sample, the stated cause of the parent's death was sudden natural death in 34.9% of cases, illness in 33.3%, accident in 17.5% and suicide in 14.3%^[4]. That sample was not representative, but it shows how easily sudden natural deaths are missed by the natural/unnatural split.

Children and caregivers in that study did not always describe the cause of death the same way, particularly after a suicide^[4]: what a child has been told is part of the circumstances too. Separate studies cover children bereaved by a parent's suicide, children bereaved by homicide and the ages and causes of parental deaths.

Across Nordic registers, deaths from external causes carry higher long-term risks

One of the largest studies of cause of death and children's outcomes covered Denmark, Sweden and Finland. Of the 7,302,013 people included, 189,094 (2.6%) had a parent die between the age of six months and 18 years^[1]. Compared with children whose parents were alive, bereaved children had a higher death rate themselves into early adulthood: 1.50 times as high overall. The gap was wider after a parent's unnatural death (1.84 times) than after a natural death (1.33 times), and widest after a parent's suicide (2.00 times). These estimates were adjusted for birth characteristics and the mother's age, parity, education and social status, among other factors^[1].

For the young person's own death from natural causes, the risk was much the same whichever way the parent had died: 1.45 times after an unnatural death and 1.44 times after a natural one^[1]. The authors had no information on the parent–child relationship, lifestyles or the shared home environment after the death^[1]. A register cannot separate shared family genes and circumstances from the effect of the death itself.

Mental health shows a similar gradient. Among 862,554 people born in Sweden in 1973–1982, a mother's death from natural causes in childhood was linked with 1.19 times the rate of outpatient care for depression in young adulthood for men and 1.15 times for women, after adjusting for sociodemographic factors (similar for a father's natural death)^[5]. Deaths from external causes (suicides, accidents or homicides) showed consistently larger effects: after a mother's death from an external cause, the rate of hospital admission for depression was 3.23 times as high for men and 1.79 times for women^[5]. The authors describe the risk after a natural death as "small"^[5].

Within unnatural deaths, the cause matters too. In Norway, among 655,477 people born 1970–2012, risks of a range of psychiatric conditions after a parent's external-cause death were especially raised after suicide and accidental falls and poisoning^[6]. In Sweden, children and adolescents whose parent died by suicide had about three times the rate of suicide of children whose parents were alive (rate ratios 3.0 and 3.1); offspring of parents who died in accidents or from other causes did not have a raised suicide rate^[3]. These are relative rates of a rare outcome with many causes, not a prediction for any child. They are a reason to make sure that support reaches these children early. Help is available, and reaching out for it, at any age, is a sign of strength.

An expected death brings its own strain

Register data show lower long-term risks, on average, after a natural death than after an external-cause one, but that does not make an expected death easy for a child: a long illness is its own stress, and it starts before the death. A US study followed children whose parent was dying of cancer. Their depression and anxiety were higher than those of children in a community sample before the death. By 7 to 12 months after it, their reports were comparable with those of similar children in the community^[7]. For these children, the hardest stretch may have been the illness, not only the bereavement.

A small US study of 63 bereaved children went further: those whose parent had died after a prolonged illness showed higher levels of maladaptive grief and of posttraumatic stress symptoms than children whose parent had died a sudden natural death, such as a heart attack. Their surviving caregivers showed the opposite pattern for depression, which was higher after a sudden natural death^[4]. The authors suggest that anticipated deaths "may contain etiologic risk factors" for maladaptive grief and posttraumatic stress in children^[4]. The sample was small and clinical, so the size of the difference should not be taken at face value, but it cautions against assuming that a child who "knew it was coming" is coping well.

Swedish register data point the same way. Among 117,518 people born in Sweden in 1992–1999, those bereaved of a parent at ages 7–24 started antidepressant treatment at a rate of 27.5 per 1,000 person-years, against 18.2 among matched people who were not bereaved^[8]. The raised risk did not differ overall between natural and unnatural deaths, though a mother's unnatural death was linked with a raised risk from the fourth year onward. What made a larger difference was the surviving parent's mental health: when the surviving parent had received psychiatric care before the death, bereaved young people started antidepressants at about twice the rate of the matched group (hazard ratios 2.11 after a father's death and 2.14 after a mother's)^[8]. We look at this in our study of the surviving parent's wellbeing.

Many children go into an expected death unprepared

An expected death is expected by someone, not always by the child. A nationwide Swedish survey reached young adults who had been 13–16 when a parent died of cancer, six to nine years earlier. Of 851 eligible young people, 622 (73%) took part^[2]. Almost all (98%) said teenagers should be told when a parent's death is imminent, meaning a matter of hours or days. Yet only 59% said they had been told. Few heard it from professionals: 8% were told by professionals alone and 7% by parents and professionals together. Up to a couple of hours before the death, 43% had not realised it was imminent^[2].

A common reason was that one or both parents, together with the teenager, had kept up a sense that the illness was not that serious; in 80 cases neither parent had known that death was close^[2]. That is not a failing of parents: prognosis is uncertain, and an expected death can still come suddenly. It is a gap that health professionals are well placed to help fill.

What happens around an expected death seems to matter later. In the same Swedish group, 57% said they had not had a way to grieve that felt okay in the first six months. Not having one was linked with unresolved grief six to nine years after the death, at 4.32 times the odds^[9]. About a quarter (24%) said they had hidden their grief to protect the surviving parent. Having talked with the dying parent about what was important, and good family cohesion, were among the things linked with having an okay way to grieve^[9]. These are associations reported years later, not proof of cause, but they point to the months before a death as a time when support can reach children.

Norway has written this into law: health professionals are required to help children who are "next of kin", meaning a close relative is sick, dying, addicted or imprisoned^[10]. A decade on, a survey of 2,811 Norwegian students in health, social care and teacher education found that 61.9% said their own course had not taught them about such children^[10]. See also our study of hospice and palliative-care support for children.

After a sudden death, most children's grief eases, but some need more

The most detailed follow-up of children after a sudden parental death comes from a US cohort. Families were recruited through coroners' records and advertisements after a parent died by suicide, an accident or a sudden natural death^[11]. Among 182 children aged 7–18, grief eased over time for most. In 30.8%, grief was higher at nine months and then gradually came down. In 10.4%, grief reactions showed no change 33 months after the death^[11]. Children in that last group more often had a history of depression before the death, and prolonged grief in the child or the surviving caregiver was linked with a higher risk of new depression^[11]. Grief that does not ease is covered in our study of prolonged grief in children.

Following 216 bereaved and 172 non-bereaved young people for up to seven years, the same team found the bereaved group had higher rates of psychiatric disorder, parental psychiatric disorder and maltreatment even before the death^[12]. After allowing for those earlier differences, bereavement was still linked with more new depression, posttraumatic stress disorder and difficulty functioning in daily life. New depression peaked in the first two years and occurred mainly in children who were 12 or younger when their parent died. Young people bereaved by all three causes (suicide, accident and sudden natural death) showed more difficulty functioning at every point^[12].

So for some children the effects of a sudden death show up over the next two years, not only in the first weeks. And sudden natural deaths, such as a heart attack, were linked with lasting difficulties too, though registers count them as "natural". Children's needs depend on more than the cause on a death certificate: their age, earlier health, what they were told, and how the adults around them are coping.

What the evidence asks of us

The research does not support ranking bereaved children by how their parent died. It supports help that fits each family's circumstances, at the right time.

• Reach children bereaved by external causes early, and keep in touch. Swedish researchers conclude that children bereaved by external causes, and those bereaved very young, should be given priority for preventive support^[5]. New depression peaked in the first two years after a sudden death in the US cohort, so support that stops after a few weeks may end too soon^[12].
• Do not overlook sudden natural deaths. Children bereaved by a sudden natural death had lasting difficulties too^[12]; services that prioritise by cause of death can miss them.
• Start support before an expected death. Children's distress can be raised during a parent's terminal illness^[7], and many teenagers did not know the end was near^[2]. Hospitals and hospices are well placed to ask whether a patient has children and what they know. Norway's legal duty on health professionals is one model, though training has not yet caught up^[10].
• Support the surviving parent as part of supporting the child. In Sweden, the surviving parent's mental health made a larger difference to children's antidepressant use than the cause of death^[8]. A systematic review of 17 studies of support programmes for bereaved children found that 14 worked with both children and their surviving parent, and that supported parents could better support their children^[13].
• Collect better data. No country records whether a parent's death was expected, or what children were told. Recording the circumstances consistently would let support be planned around what children actually face.

For more on the support itself, see our study of what helps bereaved children, and the full research library on children bereaved of a parent.

Language: this piece uses plain words such as “died” rather than euphemisms, because they are clearer. Where it discusses suicide, it follows the Samaritans’ media guidelines. Registers use the terms “natural” and “unnatural” death; we keep them where a study does, as technical categories.

Why we're publishing this

Children bereaved of a parent are often sorted, formally or informally, by how the death happened, and those facing an expected death can be missed because it was "anticipated". We stand alongside bereaved children, their families and the charities, hospices and schools that support them. The evidence shows that both groups have real needs, and that the time to reach children often begins before a parent dies.

How to read this data

Most figures come from national registers in Denmark, Sweden, Finland and Norway. They cover whole populations, but measure natural versus unnatural deaths, not whether a death was expected, and adjust for some family factors but not all. Rate ratios, hazard ratios and odds ratios are different measures and are reported as each study gave them. The US studies of sudden death (one cohort) and of expected deaths (one study of children whose parent had cancer, and a small clinical sample) are much smaller and do not represent the country. The Swedish teenage survey was nationwide, but answered six to nine years after the death. We found no comparable evidence from low- and middle-income countries, and no national data anywhere on how many children are told in advance that a parent is dying.

Use this data

Free to cite with attribution to Understanding Bereavement. Charities, schools, services and journalists are welcome to reuse these figures and charts. For the underlying figures as a spreadsheet, get in touch.

Important: This study summarises published research about groups of people for general information. It is not medical advice or bereavement support, and it cannot describe or predict anything about an individual child or family. If you are worried about a child or about yourself, please speak to a GP or another qualified professional.

Sources

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