The Grief of Peer Loss Among Adolescents: A Narrative Review

Introduction

The loss of a loved one is typically distressing, with grief symptoms gradually subsiding over time.¹ However, approximately 5–10% of individuals experience prolonged and intense grief reactions.^2,3 Peer death is one of the most commonly experienced losses among teenagers during the development phase.^4,5 It is estimated that approximately 5% of adolescents in Western societies may experience the death of a close friend before reaching the age of 15.^6,7 Adolescent mortality is frequently attributed to accidents, suicides, and homicides, which significantly heighten the risk of traumatic bereavement among their peers.⁸ Compared to natural losses, these sudden and distressing losses elevate the risk of intense and complicated grief reactions.^9,10 Data from an empirical study indicate that 16% of adolescents meets criteria for complicated grief following a peer loss.¹¹ At 18 months post-loss, 21% of adolescents report a high and unremitting level of grief symptoms,⁴ and by 3.5 years, the prevalence of complicated grief increases to 69%.¹² Peer loss has a profound impact on adolescents,^13–16 whose grief may adversely affect their physical and mental health, as well as their overall well-being.¹⁷ Furthermore, it could impair social functioning and academic performance, leading to significant reductions in attention span, emotional problems such as depression and anxiety, and an increased risk of substance abuse.^18,19

Friendship and kinship share similar psychological bonds,^20–22 suggesting that the bereavement following the loss of a peer is akin to that experienced after the death of a sibling.²³ However, the nature of grief following peer loss differs from that after the loss of a relative, due to the distinct identities involved. Drawing from the theory of disenfranchised grief, levels of grief and avoidance are associated with the subjective perception about peer loss. Because peers are not categorized as family members, peer loss often results in a form of grief that is unrecognized^24–26 and, thus, suppressed and overlooked. The grief in adolescents is characterized by the inability to mourn at the site of a peer’s death,¹⁰ feeling discomfort and a lack of empathy when sharing grief with families, friends, or teachers,²⁷ and the exclusion of peer groups from external support systems, which are typically reserved for the deceased’s relatives.²⁷ During adolescence and early adulthood, individuals perceive a decrease in parental support but an increase in peer support.²⁸ Friendships become more positive and significant during this stage. Friends play a crucial role and are integral to the attachment patterns of this period.^29,30 Friends offer a sense of belonging distinct from familial connections,³¹ highlighting the unique impact of peer loss compared to the loss of relatives. Furthermore, peers are of similar age to adolescents, and the loss of a peer serves as a reminder of one’s own mortality, potentially intensifying the grief following a peer’s death.²⁷ Findings from an empirical study show that adolescents may experience higher levels of grief following the loss of a peer than the loss of a grandparent.³² Additionally, it has been observed that the loss of a friend induces more traumatic grief than the loss of a distant family member.^16,33 The Continuing Bonds Theory³⁴ proposes that the living maintain an intrinsic and continuous connection with the deceased after their death. Grief after the loss of a peer becomes the only form of contact and bonding between adolescents who do not have a formal mourning status and their deceased friends. The Dual Process Model of Grief³⁵ argues that after a loss, people usually oscillate between loss-oriented and restoration-oriented coping. Due to the identity of friends, teenagers may remain longer in the loss-oriented phase, increasing the risk of developing complicated grief.

Most existing studies on bereavement in children and adolescents have focused on the loss of a parent or sibling due to illness or trauma.^36–41 Studies on non-relative loss have been predominantly conducted among the elderly,^42–45 and adolescent bereavement still remains a relatively understudied area.^4,14,46–48 Given the lack of a formal definition of grief due to peer loss in the existing literature, and considering that the majority of available studies focus on adolescents who have lost lovers and close friends, this review defines adolescent grief following peer loss as the grief experienced by adolescents after the death of a lover, close friends, or friends. This review aimed to provide a narrative summary of existing research on the grief of adolescents following the peer loss, specifically focusing on the manifestations of grief, factors associated with grief reactions and intensity, and potential interventions to support affected adolescents. By consolidating these findings, this review aims to enhance the understanding of adolescent grief in the context of peer loss, highlight the complexities and unique challenges associated with this experience, promote attention in this research field, and provide insights and references for the prevention, assessment, and intervention of grief following peer loss.

Methods

A literature search was conducted using online databases (Web of Science, ScienceDirect, and PubMed) from January 1, 2014, to October 12, 2024. Studies published in English, employing quantitative or qualitative research methodologies, and focusing on adolescent grief following peer loss were included. The search ultimately identified 13 eligible studies for this review. The literature search strategies are shown in Table 1, developed with guidance from a university expert librarian. Characteristics of the included studies are shown in Table 2.

Table 1 Literature Search Strategy

Table 2 Characteristics of Included Studies

The Manifestation of Grief After the Peer Loss

Intense and Enduring Reactions

The disenfranchised nature of grief arising from the death of a friend, coupled with the often unnatural circumstances surrounding such losses, could result in a delayed grieving process.^53–55 This delay may lead to prolonged and intensified grief,^4,11 which could persist for up to 8.5 years.⁴⁷ In this context, an empirical study indicates that the most significant decrease in grief intensity occurs within the first 2.5 to 3.5 years following the loss of a peer.⁴⁷ A comparative study has suggested that the levels of trauma response and grief caused by the loss of a peer are higher than those caused by the loss of a close family member.²⁷

Diverse and Strong Physiological Responses

Bereavement may trigger grief reactions resembling symptoms of post-traumatic stress disorder (PTSD), including panic attacks, inexplicable breathing difficulties or hyperventilation, particularly when exposed to reminders of the death. Sleep disturbances are also common. A qualitative research indicated that adolescents who have experienced the death of a friend are more prone to difficulties in falling asleep, frequent nightmares, and disrupted sleep.⁴⁸

Long-Term Impairment of Functioning and Mental Health

Grief after peer loss has the potential to substantially transform the daily lives of adolescents. It leads to increased levels of worry and rumination about death, subsequently causing death-related fear, which may diminish adolescents’ well-being, impair mental health, and disrupt social functioning for up to four years.⁴⁹ The specific manifestations of this grief include: (1) feelings of profound loneliness and emptiness; (2) self-isolation from others; (3) reduced energy and concentration, with some adolescents struggling to engage in daily activities and experiencing difficulty returning to a sense of normalcy; (4) social withdrawal, as some individuals are unable to enjoy social interactions as they once did, leading to disengagement from social life; and (5) reluctance to share their grief with others, resulting in the internalization of their emotions.⁴⁸ Furthermore, a study of street youths⁵⁰ found that when a peer died from a street drug overdose, the surviving adolescents were at a heightened risk of becoming ensnared in a detrimental cycle characterized by drug abuse, social isolation, and self-harm.

Factors Associated with Grief After the Peer Loss

Sex Difference

Research has shown that following the loss of a friend, girls tend to experience more complex and intense grief reactions compared to boys.^14,27 The impact of grief on life satisfaction is also more prolonged in girls, with reduced life satisfaction persisting for two years or more.¹⁴ This disparity may be attributed, in part, to differences in social networks and emotional bonds.⁵⁶ Compared to boys, girls typically have smaller social networks but form deeper emotional connections, making it easier for them to experience and express emotions, intimacy, and support within relationships. Consequently, the loss of a friend may also entail the loss of these rich emotional experiences, close contact, and genuine support, leaving girls more deeply affected by grief. The frequent and meaningful exchanges that characterized these relationships may intensify their sorrow.

In contrast, boys may encounter difficulty reconciling feelings of vulnerability with societal ideals of strength and stoicism. Their grief responses, which may include feelings of emptiness, anger, emotional restraint, and sentimentality, often conflict with the traditional masculine expectation to appear composed.⁵⁷ As a result, boys may be more inclined to suppress their grief and present a calm demeanor in line with social norms. This suggests that boys are more likely to internalize their grief and conform to societal expectations of emotional control when faced with the death of a friend.

Personality Characteristics

Studies indicated that adolescents with different personality traits exhibit varying levels of grief intensity and recovery following the death of a friend. Studies utilizing the NEO Personality Inventory have found that individuals with high scores in Neuroticism tend to be more emotionally vulnerable, experience greater difficulty adjusting to the loss, and exhibit stronger grief reactions.⁵⁸ In contrast, adolescents with high Agreeableness demonstrate better grief recovery, as agreeable individuals are more likely to be included in social circles by others who are also grieving, thereby increasing the frequency of communication.^51,59 Such active social networks facilitate more effective grieving processing.

Additionally, research has shown that adolescents with high self-esteem possess greater psychological resilience than those with lower self-esteem. They are better equipped to cope with the stress of loss, process their grief more rapidly, experience less intense grief reactions, and have a shorter grief duration.¹⁴ Conversely, individuals who exhibit social avoidance following the loss of a friend tend to have lower adaptability and resilience to grief compared to those who remain socially engaged.¹⁴

Vulnerability of Adolescents

Adolescence is a transitional phase from childhood to adulthood, during which individuals encounter various psychological tasks, including the development of identity, independence, and self-image⁶⁰ The death of a friend not only results in the loss of a close personal bond but also refers to the heightened sense of mortality. Moreover, the psychological immaturity of adolescents, combined with a lack of appropriate education on death and grief, leaves them unequipped with adequate coping skills. Consequently, the duration of grief in adolescents tends to be prolonged, the grief reactions tend to be complicated, and the intensity of grief tends to become more severe over time.^13,61

Frequency That Negative Information Appears

Continuous and extensive media coverage of traumatic events, along with frequent official obituaries, may intensify stress and serve as a constant reminder of death,²⁷ thereby impeding the healing process.⁵² It is only after the acute events subside, media attention diminishes, and legal proceedings conclude, that individuals are afforded the space to start addressing their grief and engage in the post-death grief recovery process.⁴⁷

Social Networking, Collective Grief and Collective Healing

When a member of a social network dies, others within the network experience various levels of bereavement-related grief, leading to what is referred to as network stress. This stress is often influenced by the size and structure of the social network, with larger networks and unnatural deaths intensifying the stress.⁶² However, a study of 15,000 Facebook users revealed a contrasting perspective. The study found that social network is elastic. When someone within the network passes away, there is often an increase in communication among the deceased’s friends. This heightened online social interaction may offer support during acute grief, helping to stabilize the grieving process for up to a year.⁵¹

Interpersonal Relationship and Emotional Closeness

Research has demonstrated a strong connection between the quality and depth of relationships and the intensity of grief. Relationships characterized by frequent conflicts that were successfully resolved tend to be closer and of higher quality, leading to higher grief level following a death¹³ This is also linked to emotional closeness.^13,23,46 Adolescents who shared a deeper emotional bond with the deceased exhibited stronger grief reactions and were at a heightened risk of developing complicated grief symptoms.¹⁵

Comorbidities with PTSD and Depression

After learning of a friend’s death, adolescents may experience persistently high levels of post-traumatic stress and depressive symptoms, which are closely associated with ongoing grief reactions. This could pose significant challenges to their adaptive resources in managing the dual demands of emotional-cognitive trauma and the grieving process.⁴

Interventions for Mitigating Grief After Peer Loss

Raising Awareness of Adolescent Grief from Peer Loss Among Teachers and Medical Professionals

Schools and hospitals serve as critical points of contact for adolescents following the death of a friend. Identifying adolescents who have experienced peer loss and conducting regular psychological assessments of grief, depression, anxiety, and sleep quality, especially the requirement of dynamic tracking of their suicide risk. Adolescents at high risk of suicide should be promptly referred to psychiatric services. It is also necessary to popularize the grief after peer loss. In the school setting, it is essential to provide professional support to affected communities, enabling educators to better assist their students and identify those who are particularly vulnerable.⁴ In hospitals, general practitioners and primary care health providers should be aware of the potential vulnerability of bereaved individuals, which may last for up to four years after the loss. This awareness may help them proactively recognize grief-related symptoms and offer appropriate support.¹⁴

Individual and Group Interventions Led by Professionals

Timely professional individual and group interventions could assist adolescents in identifying and managing grief. For individual interventions, as post-traumatic stress and depressive symptoms are closely tied to grief, it is essential to help adolescents address these symptoms to foster a more adaptive grieving process. In terms of group interventions, formal and informal peer groups allow individuals with peer loss to share post-loss experiences, exchange information about the deceased, promote meaning reconstruction, and carry out related activities and rituals,⁴⁹ which aid in the recognition, treatment, and healing of grief.⁴ Although family support may be less effective than peer support in mitigating grief, it is an essential component of collaborative interventions for grief. As such, family therapy should be encouraged and included in group interventions related to grief. Death and life education plays an important role during the adolescence. It may help adolescents correctly recognize life and death, improve the management of death-related events, such as peer loss, and master the skills of adjusting the negative emotions brought by the loss,⁶³ which could reduce the impact of grief after the peer loss.

Establishing a Social Support Network and Providing Companionship and Assistance

Social support plays a crucial role in helping individuals recover from traumatic events.^64,65 However, the nature and impact of social support provided by the community may vary, especially in the aftermath of a traumatic event that affects the entire community, such as the great loss of its young members. For adolescents dealing with peer loss, it may be challenging to receive adequate support and comfort from peers who are themselves traumatized by the loss of many young people in the community.⁴ Therefore, both formal and informal support networks should be established to alleviate persistent grief. Such social support focuses on connecting individuals to broader social networks or religious communities to provide emotional support,^14,66 which is essential for promoting healthier bereavement adjustment, reducing feelings of loneliness and despair, and thus decreasing the likelihood of prolonged depressive and physical symptoms.⁶⁷

Implications

Peers play a pivotal attachment role during adolescence. Grief following the loss of a peer is comparable to that experienced after the loss of a family member. Due to its often unacknowledged nature, grief after peer loss is frequently suppressed and neglected. This review synthesizes and discusses the manifestations, factors, and interventions of such grief, not only broadening the scope of bereavement research but also providing a new perspective to understand adolescent grief following peer loss. It emphasizes the importance of early intervention, complements the theoretical framework of post-bereavement grief, and offers new avenues for future research. The main findings from this review are summarized in Figure 1.

Figure 1 Manifestations, associated factors and interventions of grief after peer loss.

Future Research

This review has several limitations. First, few of the reviewed studies used a longitudinal research methodology, resulting in very limited data on the changing trajectories of grief in adolescents. Second, there is inadequate research on factors associated with grief following peer loss, particularly modifiable and protective factors. Third, the development of theoretical frameworks for interventions for this type of grief and clinical trials to assess their effectiveness is still very limited. More theoretical and empirical studies are needed to fill these knowledge gaps.

Based on this literature review and our clinical experiences in grief counseling for adolescents bereaved due to peer loss, we have identified four main issues that need to be addressed as follows.

The Psychological Mechanisms Underlying the Effects of Different Forms of Unnatural Death on Grief Following Peer Death

Unnatural deaths, including accidents, suicides, and homicides, elicit more complex and enduring grief responses. Current research primarily focuses on large-scale traumatic events, such as the July 2011 terrorist attack in Norway or fatal traffic accidents that result in numerous casualties.^4,47,48 In contrast, there is a notable lack of research examining the grief experienced by adolescents following a friend’s suicide.

The significance of grief resulting from a friend’s suicide warrants serious attention, particularly given the substantial increase in adolescent suicide rates following the COVID-19 pandemic.⁶⁸ Unlike accidental deaths, suicides involve planned and deliberate actions and are often accompanied by social stigma.⁶⁹ Adolescents may grapple with conflicting emotions, including contempt for the act itself and a profound sense of guilt for not recognizing early warning signs of suicide. These emotional complexities can lead to varied forms and intensities of grief responses.⁷⁰ Future research should focus on examining the grief reactions of adolescents who have lost peers to suicide and investigate how different forms of unnatural death impact the grieving process.

The Variations in Symptom Presentations of Grief Across Different Cultural Settings and the Development of Culturally Appropriate Grief Interventions

Only one of the included studies examined grief in street youths following peer loss, while the remaining studies focused on grief in school students. The street and school environments represent different subcultural settings, as street youths are often marginalized, characterized by poverty, violence, drug abuse, and crime. However, both qualitative and quantitative data on the grief manifestations, duration, associated factors, and intervention strategies for these particularly vulnerable groups are still very scarce.

Importantly, differences in grief reactions after peer loss between Western and Eastern adolescents need further examination. Eastern cultures emphasize collectivism and emotional restraint, while Western cultures highlight individualism and emotional expressiveness. Most of the included studies were conducted in Western social environments. Further qualitative and quantitative studies are needed to investigate the different expressions and coping styles of grief within diverse cultural contexts.

The Effects of Family Dynamics on Grief After Peer Loss

The lack of family support exacerbates adolescents’ experience of grief after the loss of a peer.¹⁶ Adequate family support, which is more important than teacher and school support, can help bereaved adolescents navigate the grief of losing a peer. However, such beneficial effects vary and are influenced by family dynamics. Family members’ attitudes toward grief and parenting styles also play a key role. Longitudinal studies are warranted to examine the relationships between grief and factors such as loss history, family grief education, coping styles, and parents’ involvement in grief handling.

Interventions for Grief Following Peer Loss

No specific interventions were discussed in the included studies, indicating that interventions for peer loss-related grief among adolescents remain at an initial stage and confirming that grief after peer loss is often neglected in scientific research. Future research is needed to develop theoretical models of grief after peer loss and their corresponding assessment tools, examine the feasibility and effectiveness of various psychotherapies for mitigating grief—such as cognitive behavioral therapy, narrative therapy, acceptance and commitment therapy, and group therapy—and develop clinical guidelines for medication treatments addressing comorbid depression, PTSD, or sleep disorders.

Conclusion

Peer death is one of the most significant and frequently encountered losses among adolescents during their developmental phase. Unlike the loss of family members, the grief associated with peer death is often disenfranchised, lacking societal recognition and support. This lack of recognition makes it more difficult for adolescents to openly express or process their grief, leading to a longer grief duration, complicated grief reactions, and higher grief intensity, which can significantly impact their academic performance, as well as their physical and mental health. Numerous factors, such as sex, personality traits, the quality of the relationship with the deceased, emotional depth, exposure to negative news, and comorbid mental disorders, are closely linked to variations in grief intensity and duration. These findings underscore the need for tailored interventions. Raising awareness among relevant stakeholders, such as educators and healthcare providers, about the unique grief adolescents experience following peer death is critical for timely identification and support. Additionally, professional individual and group interventions, coupled with strong social support networks, are necessary to mitigate feelings of loneliness and social withdrawal that accompany grief. Despite advances in understanding adolescent grief, significant gaps remain. The effects of different forms of unnatural death, cultural settings, and family dynamics on grief after peer loss have not been fully explored. The interactions between these factors and the underlying mechanisms of grief are still unclear. Research on intervention measures is lacking, and the effectiveness of various therapies for this type of grief remains untested. To advance the theory and practice of addressing grief, future research should focus on assessment, early recognition, and timely and effective intervention.