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Child age and sex. Child characteristics such as age and sex are known in general to influence both the emergence and form of child psychopathology. For example, reported rates of depression increase with child age, such that while they are approximately equal between boys and girls in middle childhood, by adolescence depression is more common in girls (Harrington, 1994). Rates of externalizing disorders are higher in boys than in girls (Earls, 1994). Do such characteristics exert a moderating effect upon the outcome of bereaved children?
(1) Child age: Parental death is likely to have a differential impact according to the age of the child. For example, a mother's death will result in more extensive changes in caretaking routines for younger children than for adolescents. Further, the child's level of emotional and cognitive development will influence both their understanding of, and responses to, death (Lansdown & Benjamin, 1985). Although clinical case studies illustrate the differences between the affective and cognitive responses of preschoolers and adolescents (Raphael, 1996), research has not established differential disturbance according to the age of the child. The most consistent findings relate to nonspecific disturbance in those under 5 years, where emotional and behavioral problems present in an age-appropriate way. For example, young children are reported to show separation anxiety, dependency, night-time fears, and widespread disturbance (Kaffman & Elizur, 1979; Kranzler et al., 1990). Younger children in the Van Eederwegh study (1982) bedwet more frequently than controls of a similar age, whereas Cheifetz et al. (1989) report that irritability and impatience was more characteristic of younger children than dysphoria. The one well-designed and robust study of young siblings (mean age 6 years) following a sudden infant death found age-appropriate widespread emotional and behavioral difficulties that include jealousy, clinginess, aggression, and anxiety (Hutton & Bradley, 1994).
Findings relating to psychiatric disorder in middle childhood and adolescence are conflicting. Two studies report that depression and guilt are more common among bereaved adolescents than those in middle childhood (Cheifetz et al., 1989; R. A. Weller et al., 1991). In contrast, Van Eerdewegh and colleagues (1985) report no significant age effects on depressive, withdrawn, or dysphoric symptoms either within or between groups. Similarly, no significant age effects are reported for somatic or anxiety symptoms (Sanchez et al., 1994; Sood et al., 1992). The reasons for these discrepancies are to be found in the age distributions within and between the different studies. For example, some studies have small samples with a wide range of ages represented, so that numbers within each age group are insufficient for meaningful analysis (Cheifetz et al., 1989; Silverman & Worden, 1992a). Others exclude children under 8 years as they cannot complete the standardized self-report measures to be employed (Gersten et al., 1991). Although there has been a great deal of interest in adolescent bereavement (see Balk, 1991 for review), adolescents tend to be either under-represented (Dowdney et al., 1999) or excluded from the research literature reviewed here (Kranzler et al., 1990). Where only adolescents have been studied, the emphasis is on clarifying the grief process during this developmental phase (Meshott & Leitner, 1992; Van Epps, Opie, & Goodwin, 1997), or developing theoretical models of bereavement (Balk, 1996). Thus, any specific effects of parental death on the mental health of this age group remain largely unexplored.
(2) Sex of the child : Sex effects are more consistent. Bereaved boys show higher rates of overall psychological difficulties, with more aggressive and acting-out behavior than bereaved girls (Dowdney et al., 1999; Elizur & Kaffman, 1982; Kranzler et al., 1990). Girls, on the other hand, exhibit more internalizing symptoms, whether assessed by parental or child report. The only difference found between young bereaved and control girls by Kranzler and colleagues was in their CBCL internalizing scores (Kranzler et al., 1990). Two-thirds of the nine children reported as severely depressed by Gersten and colleagues were girls (Gersten et al. 1991), whilst Van Eederwegh et al. (1985) report bereaved girls show significantly more sleep disturbance, bedwetting, and depressive symptomatology than control girls. Only one study in the sibling literature addresses this issue in a satisfactory manner. Hutton and Bradley (1994) found that in siblings where infants had died suddenly, boys were significantly more disturbed than bereaved girls and control children of either sex. Overall, these findings parallel those found in the general literature.
Pre-existing mental health difficulties.
(2) Prior parental mental health difficulties: Few studies have examined the impact on children of parental mental health difficulties that existed prior to the death, although Weller and colleagues examine the effect of prior parental depression and find it to be associated with depressive symptoms in bereaved offspring (R. A. Weller et al., 1991). Van Eederwegh and colleagues (1982, 1985) report that severe depressive disorder in bereaved children was more likely where the surviving parent was diagnosed as depressed both prior to and after bereavement. However, as only a very small minority of the bereaved children in that study were severely depressed, this finding should be regarded as worthy of further investigation rather than as conclusive. Increased rates of psychiatric morbidity are also found in parents, relatives, and siblings of suicide victims prior to the suicide. This may indicate a preexisting disposition to psychiatric disorder (Brent et al., 1993).
More general indices of post death parental psychological difficulties, such as GHQ scores (Goldberg & Williams, 1988) consistently and positively correlate with child CBCL scores (Dowdney et al., 1999; Pfeffer et al., 1997), and are associated with parental reports of child depression, anxiety, and conduct disorder (West et al., 1991). Similarly, significant associations are found between child and parent reports of other forms of psychological distress. Sood et al. (1992) found current parental somatization to be significantly associated with an increased frequency of headaches and abdominal pain reported by their offspring. Parental psychological distress is a significant predictor of child PTSD, depressive, and anxiety scores in the study by Pfeffer et al. (1997).
There is, of course, the possibility of a confound in any reported association between parental mental health difficulties and child disturbance when the source of information about the child is the parent themselves. Confidence can be placed in associations between parent and child outcome when studies utilize corroborative sources of child assessment, such as teacher reports (Dowdney et al., 1999; Kranzler et al., 1990), child reports (Pfeffer et al., 1997), or independent psychiatric assessment of the child (R. A. Weller et al., 1991). It would seem reasonable to conclude, therefore, that the subsequent mental health of the surviving parent is an important mediating influence upon child outcome.
(2) Family functioning: Theoretical and clinical accounts of the effects of parental death upon family relationships stress the importance of prior and subsequent family organization, cohesion, communication, and role differentiation (Sutcliffe et al., 1999). Unfortunately, the methodologically sound studies included in this review have largely ignored this potentially important influence upon child outcome. There are some indications that the bereaved children likely to be at highest risk of disturbance are those from families with a prior history of parental conflict, separations, and divorce. The risk of disturbance is also greater where children had a highly involved relationship with the deceased parent and low involvement with the surviving parent; and where families are less cohesive (Elizur & Kaffman, 1983; Kranzer et al., 1990; West et al., 1991). A number of studies also attests to the family disturbance, poor communication, and increased rates of psychiatric morbidity in families where adolescents are suicidal or have committed suicide (e.g., Brent, Bridge, Johnson, & Connolly, 1996; Hollis, 1996; Garber, Little, Hilsman, & Weaver, 1998). However, none of these sibling studies examine the impact of family relationships per se upon psychiatric outcome in the remaining children. Given the increased rates of psychiatric morbidity in parents, relatives, and siblings of suicide victims prior to the suicide, it is not possible to disentangle the effects of a preexisting predisposition to disorder and the effects of suicide upon family functioning. Moreover, in all studies, parental or child accounts of family life prior to the death are retrospective, and descriptions of contemporaneous family functioning may well be colored by current parental and child mental health status.
Other potential mediating variables. Parental death is likely to be succeeded by a series of life events for bereaved children. Domestic routines will change markedly, and may well involve a change of caretakers for young children. Financial difficulties can follow the death of a breadwinner, and necessitate moving house and school, resulting in a loss of the child's former friendships and support networks. A significant association between child reports of significant life events and child psychiatric symptoms as measured by both parental and child report has been reported in families bereaved by parental or sibling suicide (Pfeffer et al., 1997).
Although researchers have considered whether bereavement influences the child's functioning at school, the variations children themselves encounter in responses from classmates, teachers, and schools has not been adequately researched, although such variations do indeed exist (Dowdney et al., 1999, unpublished data).
As outlined earlier, a proportion of bereaved children will show a late onset of disturbance and higher rates of disturbance at follow-up than control children (Worden & Silverman, 1996). This may reflect an increased vulnerability to further loss, stressors of various kinds, and/or the life events that frequently follow a parent's death. The adoption of a theoretical research framework that conceptualizes child outcome in terms of moderating and mediating variables would serve to systematize future research in a way that would address many of the unanswered questions in this area.
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