A Systematic Review of Grief Experiences of Children Who Have Lost a Sibling

Abstract

Background:

Children who lose a sibling often receive inadequate attention, leading to lasting psychological and emotional challenges. Health care providers recognize the importance of comprehensive bereavement support but may lack knowledge for effective delivery.

Aim:

This study sought to analyze and synthesize primary research on children bereaved by a sibling to gain insight into their actual grieving experiences.

Methods:

A systematic review of qualitative studies was conducted following the Joanna Briggs Institute (JBI) methodology. The review protocol was registered on PROSPERO (CRD42022289604). Electronic databases including MEDLINE, CINAHL, PsycInfo, Scopus, and Igaku Chuo Zasshi were searched from inception to April 15, 2024. Critical appraisal was performed using the JBI Critical Appraisal Checklist for Qualitative Research.

Results:

Twenty-three articles met inclusion criteria, synthesizing experiences of 466 children. Four synthesized findings were generated: Children recognized internal and external changes in themselves after losing their siblings; children found it hard to believe their sibling had died, experienced feelings of loss and fear of death, and sometimes hid their emotions; various types of grief work allowed children to find their place after the loss, but ineffective grief work led to prolonged grief; and children’s relationships with others were either strengthened or weakened depending on others’ understanding and reactions to the loss.

Conclusions:

This review highlights the complex nature of sibling grief in children. It emphasizes the importance of recognizing children’s unique grief experiences, facilitating effective grief work, and providing appropriate support from family, friends, and health care professionals. The findings suggest a need for tailored grief support programs for children who have lost siblings, considering their cultural backgrounds. However, the low ConQual score of the synthesized findings indicates that recommendations should be considered with caution.

Keywords

bereavement child grief qualitative systematic review siblings

Introduction

Opportunities to support bereaved families have emerged in pediatric palliative care. However, after the death of a child, families report feelings of abandonment primarily by health care organizations. In particular, bereaved siblings who are often referred to as “forgotten mourners” are often overlooked because of their grieving parents.^1–2

Surviving siblings are often overlooked and report increased anxiety, guilt, sadness, loneliness, anger, depression,^3–5 and difficulties with peer and family relationships.^4,6 Additionally, it has been reported that the grief experienced by surviving siblings can persist or recur throughout their lives.^7–8 Studies have indicated that many surviving siblings are at higher risk of medical, psychiatric, and behavioral problems.^9–11 In particular, it has been suggested that siblings are more likely to experience prolonged and persistent grief reactions if they lose a sibling during adolescence.^9,12 Therefore, the passing of a sibling exerts a deep and enduring impact on the psychological and emotional well-being of surviving siblings.¹³

Children often feel overlooked after the loss of a sibling, with limited opportunities to talk about their deceased siblings. Therefore, they often feel alone in their grief.^13–14 The grief of surviving siblings has been compounded by the failure of those around them to acknowledge that the children themselves are also experiencing a significant loss.¹⁵ Some parents, in particular, may be so preoccupied with their own grief after the death of their child that they do not realize that their surviving child is grieving as well. Parents’ responses to the loss of a child and their grieving patterns play a crucial role in influencing the grieving process of surviving siblings.^13,16,17 Surviving siblings often feel guilty about unresolved issues between deceased siblings and their parents.¹⁶ They then experience secondary losses from the loss of attention from grieving parents and the loss of normalcy.¹⁸ Although sibling grief is a significant issue, health care providers, such as psychologists, counselors, or social workers, may not know where to start, what is working, or what is most impactful for the family, despite understanding the importance of comprehensive bereavement support.¹⁹ Children who have lost siblings have been subject to integrative reviews. However, limitations in terms of methods and subjects^20–21 and contextual differences²² have been observed. These reviews have primarily focused on certain aspects of the impact of sibling loss and interventions for sibling loss.^23–24 Grievers’ voices play an important role in supporting siblings who have experienced their loss. Furthermore, the results of the study that qualitatively analyzed the real voices of the parties involved will be useful in building specific support measures.

Therefore, this review aimed to synthesize and appraise the primary research literature on children to determine the grief experiences of children who have lost their siblings. The findings will provide insight into the grieving experience of children who have lost siblings and will help promote pediatric palliative care.

Methodology

This review was conducted according to the Joanna Briggs Institute (JBI) methodology for conducting systematic reviews of qualitative evidence,²⁵ which adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The JBI Critical Appraisal Checklist for Qualitative Research is widely recognized as a standard tool for systematically evaluating the methodological quality of qualitative research. This standardized instrument consists of 10 essential criteria, which assess various methodological elements including the appropriateness of data collection methods and the rigor of analytical procedures.²⁵ In this review, we strove to ensure methodological rigor based on these evaluation criteria. The review protocol was registered with PROSPERO (CRD42022289604) in November 2021. In April 2024, a modification to the registration was made regarding the search.

Search strategy

An electronic database search was performed on April 15, 2024. The search strategy was developed in collaboration with an information specialist and included Medical Subject Headings and text terms related to the experiences of children and adolescents coping with the loss of a sibling. This search approach encompassed academic databases to identify published studies and gray literature sources (materials not published through traditional commercial channels) to uncover unpublished research. The language was required to be in English or Japanese, without restrictions on the publication date. The following electronic bibliographic databases were searched for published studies: MEDLINE (Ovid), CINAHL (EBSCOhost), PsycInfo (EBSCOhost), Scopus, and Igaku Chuo Zasshi. The gray literature was searched using MedNar and Data Archiving and Networked Services. This strategy used the following terms identified by a librarian (S.T.) to conduct the search: “adolescent,” “child,” “infant,” “puberty,” “teen,” “teenage,” “kinder,” “young,” “youth,” “siblings,” “sister,” “brother,” “bereavement,” “death,” “grief,” “end of life,” and “lost” (Supplementary Appendix SA1).

The screening process involved two authors (A.F. and H.M.) who independently reviewed the titles and abstracts of the identified articles. For articles that met the initial screening criteria, their full texts were assessed against the inclusion criteria, with reviews conducted by either A.F. and H.M., or A.F. and S.U. The final selection of studies to be included was determined through thorough discussion and consensus among the authors (A.F., H.M., and S.U.).

Inclusion criteria

This qualitative study included case studies. Additional research presenting qualitative evidence (excluding mixed-method studies) on the topic of interest was used, including interviews, focus groups, ethnographic studies, observations, and open-ended survey questions. Furthermore, research methodologies, such as phenomenology, grounded theory, ethnography, action research, and discourse analysis, were included.

The included studies may have been written in English or Japanese language. Studies that recorded the grief experiences of children under the age of 19 years who had lost a sibling due to illness or unforeseen accidents were included. The exclusion criteria were as follows: studies presenting quantitative data, such as those with a mixed-method design; nonempirical writings (e.g., reviews, opinion papers, and commentaries); and studies in which the cause of death of a sibling was stillbirth or suicide. Furthermore, studies in which the child’s death occurred after the 19th birthday of their sibling were excluded. In instances where research participants included individuals aged 19 years or older, the data pertaining to those aged 19 years or older were excluded from the analysis. Only the data from participants within the specified age range were considered for the analysis.

This review focused on describing the grief experiences of children who have been bereaved by a sibling because of medical illness or unforeseen circumstances. This review evaluated studies that report on the broad emotional, psychological, relational, and social effects of bereavement; the lived experience of bereavement (phenomenological features); and how these experiences are perceived and understood. We accepted any contexts in this study, such as neonatal intensive care units, pediatric intensive care units, palliative and hospice care, pediatric oncology units, and any children’s hospital or medical department that cares for children at the end of life or at home.

Methodological quality assessment

Eligible studies were critically appraised using the JBI Critical Appraisal Checklist for Qualitative Research.²⁵ The following items on the critical assessment checklist were deemed crucial for ensuring methodological quality: Q2 (congruity between research methodology and research questions/objectives), Q4 (congruity between research methodology and data representation/analysis), and Q8 (representation of participants and their voices). These questions are considered important to ensure methodological quality, particularly to guarantee logical consistency among the research questions, methodology, and analysis.

Studies that were rated “No” for any of these questions were excluded. For each study, two reviewers independently performed the critical appraisal and then confirmed the assessment of the methodological quality in pairs (A.F. and H.M., or A.F. and S.U.). Discussions between the reviewers were used to settle any disputes regarding the methodological quality.

Data extraction, synthesis, and analysis

Data were extracted from the included studies using a standardized JBI data extraction tool for qualitative evidence.²⁵ For each study, two independent reviewers (A.F. and H.M., or A.F. and S.U.) performed data extraction. The extracted data included specific details about the study populations, context, methods, and phenomena of interest relevant to the review question and objectives. To ensure consistency in the extraction process, two reviewers met to compare the data extracted from each of the included studies in Microsoft Excel. Disagreements that arose between the reviewers were resolved through discussion. No study required further information from the corresponding authors.

A finding was defined as a verbatim extract of the authors’ analytic interpretation. For consistency, findings were extracted at the same level (e.g., themes and categories) across a study. Each finding was accompanied by an illustration, which included quotations in participants’ voices to represent the meaning. Each finding was appraised in credibility as “unequivocal (U),” “credible (C),” or “unsupported,” according to the criteria in the JBI Manual for Evidence Synthesis.²⁵ Unequivocal findings were accompanied by an illustration that was beyond reasonable doubt and therefore not open to challenge. Credible findings were accompanied by an illustration that lacked a clear association with the findings and was therefore open to challenge. Unsupported findings were not supported by an illustration and were excluded from the synthesis.

Qualitative research findings from all studies included in this review, with accompanying illustrations, were extracted and pooled. The findings and illustrations were identified through repeated readings of the text. Only unequivocal and credible findings were included in the synthesis. The findings were then categorized based on similarity in meaning. The categories and their associated findings with illustrations were confirmed by re-examining the context of primary studies and organized in Microsoft Excel and NVivo. These categories then underwent meta-aggregation, which generated a comprehensive set of synthesized findings that could be used as a basis for evidence-based practice. These were drafted by the first reviewer (A.F.) and then discussed with the other four reviewers (S.U., H.M., Y.H., and M.S.) and revised to reach consensus.

The final synthesized findings were graded according to the ConQual²⁶ approach for establishing confidence in the output of qualitative research synthesis and are presented in a Summary of Findings (Supplementary Appendix SA2). The level of confidence for each synthesized finding was scored as high, moderate, low, or very low. Qualitative studies were ranked as high quality at the starting point, and each synthesized finding was then downgraded based on dependability and credibility. The confidence rating in the synthesized findings was based on the ConQual score.

Results

Characteristics of the included studies

A PRISMA flowchart is shown in Figure 1. The search of the electronic databases identified 6183 citations. After the removal of duplicates and screening of titles and abstracts, 147 publications were subjected to a full-text review, and 45 were critically appraised. The primary reason for exclusion was that the studies did not clearly describe the data collection or analysis methods. In the Critical Appraisal Results of Qualitative Research, Q7 had the lowest percentage of “Yes” at 17.8%, followed by Q1 and Q6, which were approximately 30%. Q9 and Q10 were in the 40% range. The remaining items had a percentage of Yes of >50%, with Q2 having the highest percentage at 77.8% (Supplementary Appendix SA3). Twenty-three publications^3,27–48 met the inclusion criteria and were included in the review.

FIG. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

The participants in the majority of the 23 studies were adolescents aged 8 years or older. Of the 466 participants, approximately two-thirds were women, and most were White. The context of all studies was in a community setting. Data collection methods were semistructured interviews or narrative interviews, except for one study in which open-ended questions were used. Content analysis was the most frequently used analysis method (seven studies), followed by narrative analysis (five studies). Other methods used were qualitative analysis, thematic analysis, interpretive phenomenological analysis, and grounded theory. Most studies were conducted in the United States. The details of the included studies are shown in Table 1.

Table 1.

Summary of the Studies Reviewed According to the Year of Publication (n = 23)

Authors	Country	Aims and objectives	Participants	Methods	Findings
Balk, D.,²⁷	USA	To investigate the reactions of adolescents to the death of a sibling, with the expectation that knowledge would be helpful to teenagers who experience bereavement and would lead to the development of interventions to assist bereaved youths	33 (female: 20, male: 13) bereaved adolescents whose siblings had died 4–84 months before the study The age range was 14–19 years All participants were White and came from middle- and upper-middle-class families	Qualitative: Semistructured interviews Qualitative analysis	Emotional responses Relationships with parents Relationships with peers Effects on grades and study habit Discussions on the sibling’s death Importance of religious reliefs
Martinson, I. M. & R. G. Campos,²⁸	USA	To investigate the bereavement process in a family	31 adolescent siblings (female: 13, male: 18) from 21 families who participated in a longitudinal study (7, 8, and 9 years) of home care for children with cancer. Conducted 7–9 years after the death of patients with childhood cancer Most families were Caucasians of middle to lower socioeconomic class as measured using the Hollingshead Two-Factor Index	Qualitative: Semistructured interviews Qualitative analysis	Legacy of death experience Life changes Difficult experiences Care for and involvement with siblings Communication about sibling loss Advice
Teplow, D. R.,²⁹	USA	To explore the ways in which the loss of a sibling in childhood was experienced over time	10 adult surviving siblings (female: 8, male: 2) All participants were Caucasian Education levels were associate (3), bachelor (3), master (2), and doctor (2)	Qualitative: Phenomenological approach Open-ended and semistructured interviews Phenomenological analysis	Family and other interpersonal reactions Subjects’ affective reactions Cognitive sequelae What was helpful/unhelpful in dealing with their grief?
Rindt, S. E. M.,³⁰	USA	To investigate adolescents’ experience of the sudden and accidental death of a sibling and the impact of this experience throughout the passage of adolescence	7 female participants (Caucasian: 6, African American: 1) aged 18–30 years who had experienced this type of sibling loss when the participant was 12–15 years old	Qualitative: Semistructured interviews Qualitative analysis	Initial emotional responses were intense Suddenness of the loss allowed no opportunity to say goodbye Participants’ perceptions of the uniqueness of the relationship Identification with the deceased and assuming their characteristics after the loss Participants experienced behavioral changes after loss Participants experienced behavior changes in the family after loss Participants perceived enduring changes in family dynamics Participants attempted to hide feelings Participants experienced changes in peer relationships Religion and culture help participants negotiate the grieving process Participants reported that certain trails and skills helped the grieving process Siblings remember and incorporate the deceased into significant and meaningful life events Participants experienced the loss as a phenomenon that influences their future personal development
Kurland, L.,³¹	USA	To explore the experience of at-risk adolescents who had lost a sibling by sudden death	8 at-risk adolescents living in residential homes who lost a sibling by sudden death between the ages of 17 and 20 years. Female: 2, male: 6 Four are African–American, 3 are Latinos, 1 one is White	Qualitative: Semistructured interviews Constant comparative analysis	Initial feelings of intense shock and denial Extremely close, unique, and idealized relationship with the deceased sibling Siblings cared for and protected one another Negative behavioral changes that affected school performance Participants’ inability to understand why the death occurred Participants’ new sense or fear of mortality following their loss Participants’ increased sense of power and control in their lives Participants endorse a positive view of self Participants experienced closer relationships with their family members following their loss An ongoing relationship with the deceased sibling has helped facilitate the grieving process Participants’ beliefs in God or a higher being have helped facilitate the grieving process Participants’ experiences of the interview were positive
Nolbris, M. & Hellstrom, L A.,³	Sweden	To explore siblings’ needs and issues when a brother or sister dies of cancer	10 siblings participated in the study. The ages of the surviving siblings ranged from 10 to 30 years	Qualitative: Inspired by the phenomenology and life-world theory Semistructured interviews Content analysis	Dissatisfaction with information and support Loneliness Reactions (i.e., anxiety, anger, and jealousy) Places of refuge Mourning Memories
Sato, I., et al.,³²	Japan	To describe the characteristics of grief from the narratives of the experiences of young men who have lost a sibling to childhood cancer	Siblings of children who died of childhood cancer between 5 and 15 years ago, n = 3 (female)	Qualitative: Narrative approach Narrative interviews Narrative analysis	Strong influence from relationship with mother Transitional grief work Characteristics of grief work Direction of assistance to the bereaved family
Shipkey, N.,³³	USA	To describe the meaning of the experiences of older adolescents with sibling death; identify the negative and positive aspects of the experience; identify strategies that are perceived by older adolescents to be of value in helping them come to terms with the loss; and explain the processes used by older adolescents to live with the death of their sibling through grounded theory methodology	13 (females: 8, males: 5) adolescents who had experienced the death of a sibling 18–22 years old (median, 20 years) (6–20 years old: sibling death). All Caucasian. Nine of the 13 participants lost older siblings and 4 participants lost a younger sibling	Qualitative: Grounded theory Semistructured interviews	Hearing the news Denying the death Feeling the loss Confronting and dealing with the death Re-evaluating the way things are Making meaning Reconstructing reality
Kempson, D. & V. Murdock.,³⁴	USA	To examine, through retrospective narratives, how surviving siblings understand the loss of a sibling who died at or near birth but was never physically known in the family. This article reports the findings of this qualitative study involving adults living with the internal narrative of a deceased sibling they never knew. The study examines interpersonal and intrapersonal aspects of the unacknowledged loss of a sibling never known	15 adult siblings (female: 10, male: 5), ranging in age from 22 to 60 years 12 were White, non-Hispanic; 3 had other ethnic backgrounds	Qualitative: Phenomenological approach Semistructured interviews Thematic analysis	Memory keeping/continuing bonds Personal/unacknowledged loss Sense-making
Demmer, C. & N. Rothschild,³⁵	South Africa	To explore the feelings of the participants about losing a sibling to AIDS and allow them to describe how their lives had been impacted by this loss	11 adolescents who had lost a sibling to AIDS in South Africa. Female: 8, male: 3 Age range of the participants was from 12 to 18 years	Qualitative: Qualitative descriptive approach Semistructured and in-depth interviews Qualitative content analysis	Dealing with a sibling’s sickness Reaction to a sibling’s death The adolescents’ views about stigma Relationships with family members Living in poverty Sources of support
Barnhill, J. J.,³⁶	USA	To better understand the meaning-making process that occurs among surviving family members after the tragic loss of a teen or young adult In particular, to look at the role of family stories and rituals in understanding sudden loss and how the survivor’s role as a sibling or parent influences the grieving process	5 families, 15 individuals (early 20s to late 50s) All members of families in which a family member had died unexpectedly in adolescence or young adulthood	Qualitative: Narrative approach In-depth interviews and observation Thematic analysis	Family celebrations Family traditions Family interactions Siblings’ perspectives
Broderick, D.,³⁷	USA	To explore the bereavement experiences of fraternal twins whose cotwin has died. In particular, this study aims to focus on the fraternal twin’s experience of losing their cotwin during adolescence or older to capture the relationship experienced between the cotwins	12 bereaved fraternal twins (female: 10, male: 2) Their ages ranged from 24 to 69 years	Qualitative: Semistructured interviews Narrative analysis	The fraternal twin relationship The interaction between the twin relationship and twin loss understanding, or lack thereof, from others as central to the twin grief experience
Kamibeppu, K., et al.,³⁸	Japan	To describe Japanese adolescents’ and young adults’ experiences after losing siblings to childhood cancer	6 individuals (female: 3, male: 3) from 5 families Age during the study was 18–29 years and 5–16 years had passed since the sibling’s death Japanese children who had lost a sibling to childhood cancer up to 5 years prior and who were older than 17 years during this study	Qualitative: Narrative approach Narrative interviews Narrative analysis	Mother in another world and the sibling who became a god Return of the loving mother and the sibling as savior The poor mother and the sibling who needs my help to carry on her legacy
Flesner, J. M.,³⁹	USA	To better understand the phenomenon of sibling grief through personal narratives, explore common meanings made by bereaved siblings, and investigate strategies used by bereaved siblings to make meaning out of their siblings’ deaths	7 young adults who lost a sibling in adolescence. Female: 6, male: 1 Caucasian: 5, Latina: 1, multiracial (self-identified as Asian Indian/European): 1 Current age ranged from 19 to 37 years Socioeconomic status: working class: 2, middle class: 3, upper-middle-class: 2	Qualitative: Narrative approach Narrative interviews Narrative analysis	Identity change, with the themes of changed view of self, changed view of the world, and changed view of others Sense-making, with the themes of spiritual or religious understandings, uniqueness of sibling relationship, continued connection to the deceased, and embracing the loss Benefit finding, with the theme of seeing positives that have come as a result of the loss Assimilation and accommodation The use of metaphor Storytelling Meaning-making through action or the pursuit of life purpose Affirmation or restoration of a sense of self Comparisons of loss Questioning Negotiation through relationships Seeing “signs” as messages from deceased siblings
Neubacher, K.,⁴⁰	USA	To acquire knowledge about (1) an individual’s lived experience of sibling death in childhood, (2) the roles parents play in the grieving process, and (3) conditions and processes that facilitate healthy grieving for the child	7 females (7 memories) Participants experienced the loss of a sibling between the ages of 2 and 17	Qualitative: Phenomenological research Collecting data from memoirs Interpretive phenomenological analysis	Societal response to the sibling’s grief Changes in identity Affect restriction and fear
Brooten, D. & J. Youngblut.,⁴²	USA	To describe 6–12-year-old children’s responses 7 and 13 months after their siblings’ NICU/PICU or emergency death	31 school-age children (female: 18, male: 13). Children’s mean age was 8.4 years 20 were Black, 7 were Hispanic, 4 were White	Qualitative: Semistructured interviews Conventional content analysis	Circumstances of the sibling’s death (i.e., cause, where they were, and who told them) Funeral services and/or burial events Thinking about and talking with the deceased Fears Life changes
Brooten, D., et al.,⁴¹	USA	To describe 13–18-year-old adolescents’ responses 7 and 13 months after their siblings’ NICU/PICU death	17 adolescents participated (female: 9, male: 8). (age range, 13–18 years; median age, 15) 11 were Black, 4 were Hispanic, and 2 were White	Qualitative: Semistructured interviews Conventional content analysis	Learning about the sibling’s death and disbelief Getting through funeral services and burial events Beginning to return to normal functioning and concerns for other family members Continuing a relationship with the deceased sibling Thinking about and talking with the deceased Changes in themselves Changes in family members and friends
Collins-Colosi, K. L.,⁴³	USA	To explore the narratives of young adults who experienced the death of a sibling during their adolescence	8 participants (all female) aged between 18 and 30 years who lost a sibling between 13 and 18 years	Qualitative: Narrative study Semistructured interviews Narrative analysis	Returning to school (refuge vs. struggle) Being there (sources of support) Emotional separation (family, friends, and the lost sibling) Identification of self/moving forward (turning points following the loss) Family dynamics with departed and surviving (maintaining the lost connection)
M. Lovgren., et al.,⁴⁵	Sweden	Nationwide study to identify grieving and coping strategies of adolescent and young adult siblings who are childhood cancer survivors and to examine whether these coping strategies are associated with experiences of overcoming grief	174 siblings (female: 101, male: 73) Age range during data collection: 19–33 years	Qualitative: Questionnaire Content analysis	Thinking of their dead brother/sister and feeling the grief and expressing it Distracting or occupying themselves Engaging in spiritual and religious beliefs and activities Waiting for time to pass
Akard, T. F., et al.,⁴⁴	USA	To compare changes in siblings 1 year (T1) and 2 years (T2) after the death of a sibling from cancer, based on interviews with the surviving parent and sibling	26 siblings aged between 8 and 17 years. Female: 18, male: 8 Mean age of 12.3 ± 2.5 years White: n = 19	Qualitative: Semistructured interviews Content analysis	Personal changes Changes in relationships
Bornemisza, A., et al.,⁴⁶	Hungary	To describe how siblings could cope with the loss of a sibling in infancy, how siblings experienced loss, how bereaved parents felt, and how they remembered their deceased sibling in adulthood	20 siblings who experienced perinatal loss. Female: 12, male: 8	Qualitative: Phenomenological approach Semistructured interviews Interpretive phenomenological analysis	Spirituality Establishing the bond/continuing bonds Parental grief and mourning External reactions Transforming power of trauma Emotions Who is responsible?
C. Wallace Chi Ho., et al.,⁴⁸	Hong Kong	To address this gap by exploring the bereavement experience of younger bereaved siblings from the perspective of the bereaved child and the parents	11 bereaved siblings (6 boys and 5 girls) The mean age of the siblings is 8 (SD: 1.54; range: 5–11)	Qualitative: Semistructured interviews Thematic analysis	Parents’ unawareness of bereaved siblings’ grief I do not want you to be sad Comparison with the deceased siblings Learning how to grieve
A. DeLarco.,⁴⁷	USA	To explore the grieving reactions that emerge after the sudden and accidental death of a sibling during childhood	Four participants, all female age 22, others: 51–66 Siblings experienced the sudden and accidental death of a brother or sister during childhood, particularly between the ages of 0 and 12. At the time of the interview, these siblings were aged ≥18 years	Qualitative: Phenomenological approach Semistructured interviews Thematic analysis	Emotional difficulties Overlooked in the aftermath Parental emotional unavailability Accommodation in the family dynamic Lack of discussion surrounding death and grief Lack of support and resources Disruptions in the grieving process Lack of closure and “What-Ifs” Evolution of the grieving experience Adaptation of sibling identity Searching for meaning and self-actualization Empathy

AIDS, Acquired Immune Deficiency Syndrome; NICU; Neonatal Intensive Care Unit; PICU, Pediatric Intensive Care Unit; SD, standard deviation.

Synthesis

A total of 136 findings were collected from the included studies. Four synthesized findings and 21 categories were generated to assess the grieving experiences of children who have lost a sibling. The illustrations of each finding are shown in Supplementary Appendix SA4. The four synthesized findings were as follows: Children recognized internal and external changes in themselves after the loss of their siblings; after the loss of a sibling, the child finds it hard to believe that their sibling has died and simultaneously has feelings of loss and fear of death. Sometimes, they may hide from expressing their feelings. Various types of grief work allow children to find their place after the loss of a sibling; however, if this work does not work, the grief will be prolonged. After the loss of a sibling, a child’s relationship with others may be strengthened or weakened, depending on the depth of understanding and differences among those around them.

Children recognized internal and external changes in themselves after the loss of their siblings (Table 2).

Table 2.

Children Recognized Internal and External Changes in Themselves After the Loss of Their Siblings

Category	Findings
Changes in themselves	Cognitive sequelae (U)
	Participants experienced behavioral changes after loss (U)
	Changes in themselves (U)
	Negative behavioral changes that affected school performance (C)
Identity change	Changes in identity (C)
	Identification of self-moving forward (U)
	Identity change, with the themes of changed view of self, changed view of the world, and changed view of others (U)
	Participants endorse a positive view of self (U)
	Personal changes (U)
Change in family situation	Emotional separation (U)
	Life changes (U)
	Participants experienced behavior changes in the family post loss (U)
	Family celebrations (U)
	Living in poverty (U)
	Parental emotional unavailability (U)

U, unequivocal; C, credible.

The children experienced “changes in themselves” cognitively and behaviorally, such as becoming unable to cope with sudden changes and becoming angry. Furthermore, they felt changes in their school life, such as dropping out of school, and the impact of this loss on their schoolwork.

After the loss of a sibling, the children had felt emotionally separated from their parents and other family members and experienced behavior changes within the family. We named this phenomenon as “changes in my family’s behavior.”

After the loss of a sibling, the child experienced an “identity change,” such as a change in the view of self and the world.

Some children experienced “changes in economic conditions,” indicating that the family’s financial situation is worsening.

After the loss of a sibling, the child finds it hard to believe that their sibling has died and simultaneously has feelings of loss and fear of death. Sometimes, they may hide from expressing their feelings (Table 3).

Table 3.

After the Loss of a Sibling, the Child Finds it Hard to Believe that Their Sibling Has Died and Simultaneously Has Feelings of Loss and Fear of Death: Sometimes, They May Hide From Expressing Their Feelings

Category	Findings
Cannot believe my siblings died	Denying the death (U)
	Hearing the news (U)
	Initial feelings of intense shock and denial (U)
	Participants’ inability to understand why the death occurred (U)
	Subjects’ affective reactions (U)
Disbelief in the death of a sibling	Circumstances of the sibling’s death (U)
	Dissatisfaction with information and support (U)
	Initial emotional responses were intense (U)
	Learning about the sibling’s death and disbelief (U)
Fear of death	Affect restriction and fear (U)
	Fears (U)
	Participants’ new sense or fear of mortality following the loss (U)
	Reactions (U)
Feeling of loss	Emotional responses (U)
	Feeling the loss (U)
	Reaction to the sibling’s death (U)
	Siblings’ perspectives (U)
	Disruptions in the grieving process (U)
Hiding one’s feelings	Emotions (C)
	Participants attempted to hide feelings (U)
	Transitional grief work (U)

After the loss of a sibling, the child had feelings of disbelief in the death of a sibling (disbelief in the death of a sibling) and a feeling of not believing that the death of a sibling was real (cannot believe my sibling died). Simultaneously, they experienced feelings of loss and fear of death over time. Occasionally, the children reacted by hiding their sad feelings and emotions from their parents and others.

Various types of grief work allow children to find their place after the loss of a sibling; however, if this work does not work, the grief will be prolonged (Table 4).

Table 4.

Various Types of Grief Work Allow Children to Find Their Place After the Loss of a Sibling; However, If this Work Does Not Work, the Grief Will Be Prolonged

Category	Findings
A place of one’s own	Characteristics of grief work (U)
	Mourning (C)
	Places of refuge (C)
Care and involvement of siblings before death	Care for and involvement with sibling (U)
Care and involvement of siblings before death	Dealing with a sibling’s sickness (U)
Communication about sibling loss	Communication about sibling loss (U)
	Continuing a relationship with the deceased sibling (U)
	Discussions on the sibling’s death (U)
	External reactions (U)
	Seeing “signs” as messages from deceased siblings (U)
	Empathy (U)
Facing one’s grief	Confronting and dealing with the death (U)
	Distracting or occupying themselves (U)
	Questioning (U)
	Sense-making (U)
	Suddenness of the loss allowed no opportunity to say goodbye (U)
	The use of metaphor (U)
	Thinking of their dead brother/sister and feeling the grief and expressing it (U)
	Waiting for time to pass (U)
	What was helpful/unhelpful in dealing with their grief (U)
Protect one’s life	Effects on grades and study habit (U)
	Participants’ increased sense of power and control in their lives (C)
	Returning to school (U)
	Societal response to the sibling’s grief (U)
	Transforming power of trauma (C)
Relationship to deceased siblings	An ongoing relationship with the deceased sibling has helped facilitate the grieving process (U)
	Establishing the bond/continuing bonds (U)
	Extremely close, unique, and idealized relationship with the deceased sibling (U)
	Family dynamics with departed and surviving (U)
	Family interactions (U)
	Memory keeping (U)
	Participants’ perceptions of the uniqueness of the relationship (U)
	The fraternal twin relationship (U)
	The interaction between the twin relationship and twin loss (U)
	Thinking about and talking with the deceased (U)
	Thinking about and talking with the deceased (U)
	Lack of closure and “What-Ifs” (U)
	Evolution of the grieving experience (U)
	Adaptation of sibling identity (U)
Religious or cultural support	Assimilation and accommodation (U)
	Engaging in spiritual and religious beliefs and activities (U)
	Funeral services and or burial events (U)
	Importance of religious beliefs (U)
	Life changes (U)
	Participants’ beliefs in God or a higher being have helped facilitate the grieving process (U)
	Religion and culture help participants negotiate the grieving process (U)
	Sense-making, with the themes of spiritual or religious understandings, uniqueness of sibling relationship, continued connection to the deceased, and embracing the loss (U)
	Spirituality (U)
	Getting through funeral services and burial events (U)
	Learning how to grieve (U)
Remembering the deceased and making sense of their death in your own way	Family traditions (U)
	Making meaning (U)
	Memories (U)
	Participants’ experiences of the interview were positive (U)
	Reconstructing reality (U)
	Siblings remember and incorporate the deceased into significant and meaningful life events (U)
	Storytelling (U)
	Searching for meaning and self-actualization (U)
Take on the deceased	Identification with the deceased and assuming his/her characteristics after the loss (U)
	Negotiation through relationships (U)
	Who is responsible? (U)
Trails and skills helped the grieving process	Affirmation or restoring a sense of self (U)
	Benefit finding, with the theme of seeing positives that have come as a result of the loss (U)
	Meaning-making through action or the pursuit of life purpose (U)
	Participants experienced the loss as influencing their future personal development (U)
	Participants reported that certain trails and skills helped the grieving process (U)
	Re-evaluating the way things are (U)

After the loss of a sibling, the child experienced getting through funeral services and burial events. Furthermore, they attempted to protect or maintain their lives, continue their ongoing schoolwork, and behave calmly. Through grief work, the children found a place of refuge or safety. Moreover, they remembered their deceased siblings and made sense of their deaths. Specifically, they faced their grief, communicated with their parents, siblings, and friends about the loss of a deceased sibling, continued their relationship with the deceased sibling, and imitated the deceased sibling or took over what the deceased sibling was doing.

Reviewing the way things are, seeing the positives of the loss, and talking to others about the deceased sibling helped facilitate the grieving process for the children. For some children, religious or cultural support facilitated the grieving process. In contrast, for some children, the inability or unwillingness to express their grief resulted in poor grief work and prolonged grief (transitional grief work).

After the loss of a sibling, the child’s relationship with others may be strengthened or weakened, depending on the depth of understanding and differences among those around them (Table 5).

Table 5.

After the Loss of a Sibling, the Child’s Relationship with Others May Be Strengthened or Weakened, Depending on the Depth of Understanding and Differences Among Those Around Them

Category	Findings
Others cannot understand my experience	Comparisons of loss (U)
	Loneliness (U)
	Personal unacknowledged loss (U)
	Understanding, or lack thereof, from others as central to the twin grief experience (U)
	Overlooked in the aftermath (U)
Relationships with parents or family	Relationships with parents (U)
	Relationships with family members (C)
	Changes in family members and friends (U)
	Changes in relationships (U)
	Accommodation in the family dynamic (U)
	I do not want you to be sad (U)
	Family and other interpersonal reactions (U)
	Participants experienced closer relationships with their family (C)
	Participants perceived enduring changes in family dynamics (U)
	Return of the loving mother and the sibling as savior (U)
	Siblings cared for and protected one another (U)
	Sources of support (U)
	Beginning to return to normal functioning and concerns for the family members (U)
	Being there (U)
	Difficult experiences (U)
	Emotional difficulties (C)
	The poor mother and the sibling who needs my help to carry on her legacy (U)
	Strong influence from relationship with mother (U)
	Comparisons with the deceased siblings (U)
	Lack of discussion surrounding death and grief (U)
	Parents’ unawareness of bereaved siblings’ grief (C)
	Legacy of death experience (U)
	Mother in another world and the sibling who became a god (U)
	Parental grief and mourning (U)
Relationships with friends	Participants experienced changes in peer relations (U)
	Relationships with peer (U)
	The adolescents’ views about stigma (U)
	Lack of support and resources (U)

The children felt a sense of loneliness from the experience that others could not understand; this phenomenon was referred to as “Others cannot understand my experience.”

Regarding relationships, children may be brought closer to their friends by spending time together; however, the relationship may be weakened by a friend’s interest in the cause of a sibling’s death or by a misguided understanding of the sibling’s death.

Some experiences showed positive changes, such as children having closer relationships with their families and supporting each other after the loss of a sibling, whereas other experiences showed that relationships were diluted or worsened due to family concerns and grief differences. Furthermore, some experiences changed from negative to positive and vice versa during the grief process (relationships with parents or other family members).

Discussion

This qualitative systematic review explored the grieving experiences of children who have lost a sibling. Four synthesized findings were developed to understand the grieving experience in this group. The synthesized findings should be worded to emphasize a line of action that provides the basis for developing recommendations.⁴⁹ Therefore, we named the synthesized findings by sentence(s) that accurately conveyed the meanings to generate a set of statements.

“Children recognized internal and external changes in themselves after the loss of their siblings.” In this synthesized finding, because of the distinct and powerful nature of sibling relationships, children may be uniquely affected by the death of a sibling.^50–52 Thus, children experienced cognitive and behavioral, life, and identity changes after the loss of a sibling. Furthermore, children also experienced changes in their family’s economic situation due to the death of their siblings. Some children stopped going to school after the loss of a sibling, which is said to have socioeconomic consequences, including income, social assistance, and teenage pregnancy rates.⁵³ This emphasizes that the death of a sibling changes the economic situation in the family. After the death of a sibling, parents also experience grief and experience symptoms associated with grief.⁵⁴ Parental reactions to the death of a child and parental grieving patterns have been reported to significantly affect siblings who are experiencing the grieving process of a sibling’s death. Rubin and Malkinson¹⁷ and Horsley and Patterson¹³ highlight this impact, which our findings corroborate by showing notable changes in parental behavior after sibling loss. For example, one participant described their mother’s profound emotional withdrawal: “she just completely fell apart, like she didn’t eat, she wouldn’t even get out of bed,” while another noted increased protectiveness: “Mom more overprotective, like when I come from school, she told me to walk home, keep the phone in my pocket.” These contrasting parental responses demonstrate how family circumstances influence children’s grief experiences.

“After the loss of a sibling, the child finds it hard to believe that their sibling has died and simultaneously has feelings of loss and fear of death. Sometimes, they may hide from expressing their feelings” described the grief reaction of a child who has lost a sibling. We believe that this is due to the situation on the part of parents, who, like the dying children themselves, often refrain from talking about their grief to protect their siblings from further suffering.⁵⁵ This study also supported the findings of Crehan et al.⁵⁶ that children may begin to fear death after the death of a sibling and may perceive each physical symptom they experience as an indicator that they are going to die. Children sometimes hide from expressing their feelings, which contributes to the risk of complicated grief and symptoms of posttraumatic stress disorder.⁵⁷ Children often cope with grief alone because they do not want to upset their grieving parents,⁵⁷ a characteristic response of children highlighted in this study.

According to Søfting et al.,⁵⁸ various types of grief work allow children to find their place after the loss of a sibling; however, if this work does not work, the grief will be prolonged and emphasized that children better understand that loss is real by participating in rituals and that it is crucial for them to be recognized as grievers by adults. Participating in rituals of the child’s own making can be seen as facilitating the child’s grief work. The loss of a sibling causes the child to experience various internal and external changes. The child then believes that psychological, physical, emotional, and spiritual safety can lead to a healthy adjustment to the loss.⁵⁹ Emotional detachment from the deceased was considered essential for successful adjustment to bereavement according to Freud and other medical models.⁶⁰ Recently, however, the importance of an ongoing connection with the deceased and accepting the loss and living with it has been emphasized.^61–62 Davies et al.⁵⁰ studied the long-term effects of childhood sibling bereavement. They found that surviving siblings maintained connections with their deceased siblings through various actions, such as displaying pictures, having ongoing conversations, and praying for protection and guidance in difficult times. Their findings emphasized the importance of these continued bonds, as children processed their sibling’s death and made sense of their loss in their own way.

“After the loss of a sibling, the child’s relationship with others may be strengthened or weakened, depending on the depth of understanding and differences among those around them.” Parents and children have their own grief after the loss of a sibling, which differs among individuals. Open communication with family members helps build a foundation for mutual relationships; however, if they do not or cannot share their feelings with each other, we believe that the child will feel alone. Children’s experiences in friendships, depending on their interactions with each other and the attitudes of the other, can be positive or negative. Peer relationships have been shown to help children cope after the death of a sibling.⁶³ Flexible friendships that allow the child to freely discuss the deceased and recall stories related to the loss are helpful to the child,⁶³ whereas the opposite can be stated as weakening the relationship. Therefore, developing comprehensive support programs would be necessary. These should focus on enhancing health care professionals’ understanding of sibling grief and the significance of sibling support, while also implementing interventions such as peer support groups, family-centered counseling, and creative expression workshops to help bereaved children process their grief and maintain healthy relationships.

Implications for Practice

Understanding grief among children who have lost a sibling is important for many health care providers to support children who have experienced bereavement so that they do not become isolated and their grief does not become more complicated. In this review, we found that children might feel loneliness by not being understood by others. Furthermore, parents who are close to the child are also experiencing grief, making it difficult for them to recognize the child’s grief. Thus, it is important for health care providers to provide correct information to the child from the time the sibling is hospitalized and receiving treatment, to understand what is worrisome for the child, to communicate openly, and to be there for the child to facilitate their grief work.

Strengths and Limitations

This is the first review to exclusively focus on the direct experiences of children facing the death of a sibling, allowing the voices of this vulnerable population to be represented. The integrative review methodology allowed us to include children’s voices from high-quality qualitative research findings. However, the children’s voices recorded were primarily those of children and adolescents from the United States; therefore, most participants were from White backgrounds. Thus, the findings are not necessarily applicable to the experiences of children from all cultures and ethnic groups. Furthermore, this review is limited to the English or Japanese literature.

Based on the ConQual score, all four synthesized findings were rated low. The reason was the existence of some “credible” illustrations, although their proportion was small in the overall analysis. Additionally, most studies did not adequately address the potential influence between the researcher and the research process (Critical Appraisal Checklist Q7). Therefore, the recommendations from this review should be interpreted with caution.

Conclusions

This review showed the experiences of children who have lost a sibling. The children experienced various changes after the death of their siblings and expressed their own grief reactions. Furthermore, the children spent time doing grief work and finding their own place in the world while continuing to bond with their deceased siblings. However, grief reactions and coping strategies may be complex, depending on the depth and differences in the understanding of those around them. The experts used the evidence from the review to reinforce their messages for the practice and expansion of grief support for children who have lost a sibling in their respective settings.

In the future, it will be imperative to establish a program tailored for health care professionals to provide support to children who have lost siblings, considering their cultural backgrounds.

Authors’ Contributions

A.F. conducted the conceptualization of the study, developed and implemented the search strategy, organized the work, screened citations and full-text articles, abstracted data, critically reviewed the quality of the included studies, performed data analysis, interpreted the results, created tables and figures, and authored the article. S.U. contributed to developing and implementing the search strategy, screened citations and full-text articles, abstracted data, critically assessed the quality of the studies, conducted data analysis, authored the article, critically revised the article for important intellectual content, and approved the final submitted article. H.M. also played a role in developing and implementing the search strategy, screening citations and full-text articles, abstracting data, critically assessing study quality, performing data analysis, critically revising the article for important intellectual content, and approving the final submitted article. Y.H. and M.S. were involved in interpreting the results, critically revising the article for important intellectual content, and approving the final submitted article. All authors have provided their consent for publication.

Footnotes

Acknowledgments

We thank Sayuka Takuma, our research librarian, for her expert assistance in developing the systematic search strategy. We also thank Ai Izumi and Takahiro Iwasaki for their help in reviewing keywords and integrating output data.

Author Disclosure Statement

The authors declare that there is no conflict of interest.

Funding Information

This work was supported by JSPS KAKENHI Grant Number JP 21K10913.

Ethical Approval and Consent to Participation

This systematic review relied on research previously conducted by other scientists and did not directly engage with human participants, human samples, or human data.

Data Access Statement

The data analyzed in this study were obtained from both publicly accessible databases and subscription-based databases. Links to freely accessible resources are provided in the reference list, and information regarding subscription access is also available for the remaining resources.

Supplemental Material

References

Rosenberg

, Baker

, Syrjala

, et al. Systematic review of psychosocial morbidities among bereaved parents of children with cancer. Pediatr Blood Cancer, 2012; 58(4):503–512; doi: 10.1002/pbc.23386

Stevenson

, Achille

, Liben

, et al. Understanding how bereaved parents cope with their grief to inform the services provided to them. Qual Health Res, 2017; 27(5):649–664; doi: 10.1177/1049732315622189

Nolbris

, Hellstrom

. Siblings’ needs and issues when a brother or sister dies of cancer. J Pediatr Oncol Nurs, 2005; 22(4):227–233; doi: 10.1177/1043454205274722

Foster

, Gilmer

, Vannatta

, et al. Changes in siblings after the death of a child from cancer. Cancer Nurs, 2012; 35(5):347–354; doi: 10.1097/ncc.0b013e3182365646

Rosenberg

, Postier

, Osenga

, et al. Long-term psychosocial outcomes among bereaved siblings of children with cancer. J Pain Symptom Manage, 2015; 49(1):55–65; doi: 10.1016/j.jpainsymman.2014.05.006

Gerhardt

, Lehmann

, Long

, et al. Supporting siblings as a standard of care in pediatric oncology. Pediatr Blood Cancer, 2015; 62(Suppl 5):S750–S804; doi: 10.1002/pbc.25821

Sveen

, Eilegard

, Steineck

, et al. They still grieve-a nationwide follow-up of young adults 2-9 years after losing a sibling to cancer. Psychooncology, 2014; 23(6):658–664; doi: 10.1002/pon.3463

Lövgren

, Sveen

, Nyberg

, et al. Care at end of life influences grief: A nationwide long-term follow-up among young adults who lost a brother or sister to childhood cancer. J Palliat Med, 2018; 21(2):156–162; doi: 10.1089/jpm.2017.0029

Davies

. Long-Term outcomes of adolescent sibling bereavement. J Adoles Res, 1991; 6(1):83–96; doi: 10.1177/074355489161007

10.

Moser

, Jones

, Zaorski

, et al. The impact of the sibling in clinical practice: Transference and countertransference dynamics. Psychotherapy: Theory, Research, Practice, Training, 2005; 42(3):267–278; doi: 10.1037/0033-3204.42.3.267

11.

Charles

, Charles

. Sibling loss and attachment style: An exploratory study. Psych Psychol, 2006; 23(1):72–90; doi: 10.1037/0736-9735.23.1.72

12.

White

. Sibling Grief: Healing After the Death of a Sister or Brother. iUniverse Star: New York; 2008.

13.

Horsley

, Patterson

. The effects of a parent guidance intervention on communication among adolescents who have experienced the sudden death of a sibling. American J Family Therapy, 2006; 34(2):119–137; doi: 10.1080/01926180500301519

14.

Rosen

. Child and adolescent bereavement. Child Adolesc Soc Work J, 1991; 8(1):5–16; doi: 10.1007/BF00757538

15.

DeVita-Raeburn

. The empty room: Surviving the loss of a brother or sister at any age. Scribner: New York; 2004.

16.

Balk

. Death and adolescent bereavement: Current research and future directions. Journal of Adolescent Research, 1991; 6(1):7–27; doi: 10.1177/074355489161002

17.

Rubin

, Malkinson

. Parental response to child loss across the life cycle: Clinical and research perspectives. The Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. 2001; 219–240.

18.

Hindmarch

. Secondary losses for siblings. Child Care Health Dev, 1995; 21(6):425–431; doi: 10.1111/j.1365-2214.1995.tb00773.x

19.

Aoun

, Rumbold

, Howting

, et al. Bereavement support for family caregivers: The gap between guidelines and practice in palliative care. PLoS One, 2017; 12(10):e0184750; doi: 10.1371/journal.pone.0184750

20.

Winger

, Kvarme

, Løyland

, et al. Family experiences with palliative care for children at home: A systematic literature review. BMC Palliat Care, 2020; 19(1):165; doi: 10.1186/s12904-020-00672-4

21.

D’Alton

, Ridings

, Williams

, et al. The bereavement experiences of children following sibling death: An integrative review. J Pediatr Nurs, 2022; 66:e82–e99; doi: 10.1016/j.pedn.2022.05.006

22.

Ridley

, Frache

. Bereavement care interventions for children under the age of 18 following the death of a sibling: A systematic review. Palliat Med, 2020; 34(10):1340–1350; doi: 10.1177/0269216320947951

23.

Lancel

, Stroebe

, Eisma

. Sleep disturbances in bereavement: A systematic review. Sleep Med Rev, 2020; 53:101331; doi: 10.1016/j.smrv.2020.101331

24.

Elsner

, Krysinska

, Andriessen

. Bereavement and educational outcomes in children and young people: A systematic review. School Psychol Inter, 2022; 43(1):55–70; doi: 10.1177/01430343211057228

25.

Lockwood

, Porritt

, Munn

, et al. Chapter 2: Systematic reviews of qualitative evidence. JBI Manual for Evidence Synthesis; 2020. Available from: https://synthesismanual.jbi.global

26.

Munn

, Porritt

, Lockwood

, et al. Establishing confidence in the output of qualitative research synthesis: The ConQual approach. BMC Med Res Methodol, 2014; 14:108; doi: 10.1186/1471-2288-14-108

27.

Balk

. How teenagers cope with sibling death: Some implications for school counselors. The School Counselor, 1983; 31(2):150–158.

28.

Martinson

, Campos

. Adolescent bereavement: Long-term responses to a sibling’s death from cancer. Special Issue: Death and Adolescent Bereavement, 1991; 6(1):54–69; doi: 10.1177/074355489161005

29.

Teplow

. Sibling loss: The death of a brother or sister in childhood. Dissertation Abstracts International: Section B: Sci Eng, 1995; 56(6-B):3466.

30.

Rindt

SEM

. Sudden sibling loss: Reflections of women on their experience during adolescence. Dissertation Abstracts International: Section B: The Sci Eng, 2002; 62(12-B):5977.

31.

Kurland

. A qualitative analysis of sibling loss by sudden death during adolescence. Dissertation Abstracts International: Section B: Sci Eng, 2003; 64(5-B):2392.

32.

Sato

, Kamibeppu

, Hoshi

. Adolescent mourning after losing a sibling to pediatric cancer. Japanese J Child Adolescent Psychiatry, 2005; 46(1):56–64.

33.

Shipkey

. Impact of sibling death on older adolescents. State University of New York at Buffalo: 2008.

34.

Kempson

, Murdock

. Memory keepers: A narrative study on siblings never known. Death Stud, 2010; 34(8):738–756.

35.

Demmer

, Rothschild

. Bereavement among South African adolescents following a sibling’s death from AIDS. Afr J AIDS Res, 2011; 10(1):15–24; doi: 10.2989/16085906.2011.575544

36.

Barnhill

. Giving meaning to grief: The role of rituals and stories in coping with sudden family loss. Dissertation Abstracts International Section A: Humanities and Social Sciences, 2012; 72(11-A):3957.

37.

Broderick

. Fraternal twins and bereavement: A qualitative study exploring the grief experience of fraternal twins during adolescence and older. Dissertation Abstracts International: Section B: The Sciences and Engineering, 2013; 74(1-B(E)): No-Specified.

38.

Kamibeppu

, Sato

, Hoshi

. The experience of Japanese adolescents and young adults after losing siblings to childhood cancer: Three types of narratives. J Pediatr Oncol Nurs, 2015; 32(3):165–177; doi: 10.1177/1043454214554013

39.

Flesner

. Alone in our grief:” Exploring how surviving siblings make meaning after the death of a brother or sister. Dissertation Abstracts International: Section B: The Sciences and Engineering, 2016; 76(10-B(E) No-Specified.

40.

Neubacher

. The experience of sibling death in childhood: A qualitative analysis of memoirs. Dissertation Abstracts International: Section B: The Sciences and Engineering, 2016; 77(4-B(E) No-Specified.

41.

Brooten

, Youngblut

. School aged children’s experiences 7 and 13 months following a sibling’s death. J Child Fam Stud, 2017; 26(4):1112–1123; doi: 10.1007/s10826-016-0647-7

42.

Brooten

, Youngblut

, Roche

. Adolescents’ experiences 7 and 13 Months Following the Death of a Brother or Sister. J Hospice Palliative Nursing: JHPN: The Official J Hospice and Palliative Nurses Assoc, 2017; 19(3):247–255; doi: 10.1097/NJH.0000000000000336

43.

Collins-Colosi

. Young adult narratives of sibling loss and bereavement during adolescence. Dissertation Abstracts International Section A: Humanities and Social Sciences, 2017; 78(6-A(E) No-Specified.

44.

Akard

, Skeens

, Fortney

, et al. Changes in siblings over time after the death of a brother or sister from cancer. Cancer Nurs, 2019; 42(1):E20–E27; doi: 10.1097/NCC.0000000000000573

45.

Lövgren

, Sveen

, Steineck

, et al. Spirituality and religious coping are related to cancer-bereaved siblings’ long-term grief. Palliat Support Care, 2019; 17(2):138–142; doi: 10.1017/S1478951517001146

46.

Bornemisza

, Javor

, Erdos

. Sibling grief over perinatal loss-a retrospective qualitative study. Journal of Loss and Trauma, 2022; 27(6):530–546; doi: 10.1080/15325024.2021.2007650 No-Specified.

47.

DeLarco

. The forgotten griever: A phenomenological exploration of childhood grief following a sudden and accidental sibling death. The Chicago School of Professional Psychology:. United States—Illinois; 2022.

48.

Wallace Chi Ho

, Grace Suk Man

, Miranda Mei Mui

, et al. Facing the loss of siblings in childhood: Interactions and dynamics between bereaved siblings and their parents. J Pediatr Nurs, 2022; 66:e1–e8; doi: 10.1016/j.pedn.2022.07.003

49.

Lockwood

, Munn

, Porritt

. Qualitative research synthesis: Methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evid Based Healthc, 2015; 13(3):179–187; doi: 10.1097/xeb.0000000000000062

50.

Davies

. Shadows in the Sun: The Experiences of Sibling Bereavement in Childhood. Routledge: New York; 1999.

51.

Foster

, Gilmer

, Davies

, et al. Comparison of continuing bonds reported by parents and siblings after a child’s death from cancer. Death Stud, 2011; 35(5):420–440; doi: 10.1080/07481187.2011.553308

52.

Barrera

, Alam

, D’Agostino

, et al. Parental perceptions of siblings’ grieving after a childhood cancer death: A longitudinal study. Death Stud, 2013; 37(1):25–46; doi: 10.1080/07481187.2012.678262

53.

Fletcher

, Mailick

, Song

, et al. A sibling death in the family: Common and consequential. Demography, 2013; 50(3):803–826; doi: 10.1007/s13524-012-0162-4

54.

Snaman

, Kaye

, Torres

, et al. Parental grief following the death of a child from cancer: The ongoing odyssey. Pediatr Blood Cancer, 2016; 63(9):1594–1602; doi: 10.1002/pbc.26046

55.

J, Wolfe

BLJ

, Kreicbergs

, Jankovic

. Palliative Care in Pediatric Oncology. Springer International Publishing: NY, USA; 2018.

56.

Crehan

. The surviving sibling: The effects of sibling death in childhood. Psychoanalytic Psychotherapy, 2004; 18(2):202–219; doi: 10.1080/14749730410001700723

57.

Dickens

. Prevalence of complicated grief and posttraumatic stress disorder in children and adolescents following sibling death. The Family Journal, 2014; 22(1):119–126; doi: 10.1177/1066480713505066

58.

Søfting

, Dyregrov

. Because I’m also part of the family. Children’s participation in rituals after the loss of a parent or sibling: A qualitative study from the children’s perspective. Omega (Westport), 2016; 73(2):141–158; doi: 10.1177/0030222815575898

59.

Schuurman

, Mitchell

. Becoming Grief-Informed: A Call to Action. Dougy Center: National Grief Center for Children & Families: 2020.

60.

Klass

, Walter

. Processes of grieving: How bonds are continued. In: Handbook of bereavement research: Consequences, coping, and care. American Psychological Association: Washington, DC, US; 2001; pp. 431–448.

61.

Attig

. Relearning the World: Making and Finding Meanings, 2001; doi: 10.1037/10397-002

62.

Neimeyer

. Traumatic loss and the reconstruction of meaning. J Palliat Med, 2002; 5(6):935–942; doi: 10.1089/10966210260499177

63.

Hogan

, DeSantis

. Things that help and hinder adolescent sibling bereavement. West J Nurs Res, 1994; 16(2):132–146; doi: 10.1177/019394599401600202