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8,865 adults in the National Survey of Families and Households 1987–1993 reveal that a father’s death leads to more negative effects for sons than daughters and a mother’s death leads to more negative effects for daughters than sons.

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J Fam Issues. Author manuscript; available in PMC 2009 Feb 10.

Published in final edited form as:

Abstract

Guided by a life course perspective, attachment theory, and gender theory, this study aims to examine the impact of death of a father, a mother, or both parents, as well as continuously living with one or both parents dead (in contrast to having two parents alive) on multiple dimensions of psychological well-being (depressive symptoms, happiness, self-esteem, mastery, and psychological wellness), alcohol abuse (binge drinking), and physical health (self-assessed health). Analyses of longitudinal data from. 8,865 adults in the National Survey of Families and Households 1987-1993 reveal that a father's death leads to more negative effects for sons than daughters and a mother's death leads to more negative effects for daughters than sons. Problematic effects of parent loss are reflected more in men's physical health reports than women's. This study's results suggest that family researchers and practitioners working with aging families should not underestimate the impact of filial bereavement on adult well-being.

Keywords: bereavement, parent death, psychological well-being, depression, health

With increased contemporary life expectancy in most developed countries, it is most typical now for individuals to experience the death of parents during adulthood rather than childhood ( Watkins, Menken, & Bongaarts, 1987; Winsborough, Bumpass, & Aquilino, 1991). Therefore, most adults have longstanding life course attachment ties and affectional bonds with their parents both as children and adults before the death of first one parent, and then the second parent, occurs. The death of parents is a typical life course transition for adults, yet surprisingly little research has examined the impact of parent loss during adulthood on psychological and physical well-being.

Previous research has indicated that parent loss in childhood is associated with significant problematic consequences ( Bowlby, 1980; Harris, 1995) and that loss of other significant family members during adulthood, such as a spouse or child, is associated with significant negative effects on well-being ( Genevro, Marshall, & Miller, 2004). Thus, it is surprising that filial bereavement and its potential consequences for adult well-being have hot received more systematic research attention. The overall aim of this study was to contribute to a population perspective on the impact of death of a mother, death of a father, death of both parents, and living without one or both parents alive (in contrast to having both parents alive) on adults' psychological well-being and physical health by examining this issue with a prospective design, using data from a U.S. national sample. We also sought to better understand how gender influences the effects of parental death on adults.

Theoretical Background

From Isolated Nuclear Families to Life Course Intergenerational Attachments

Guiding theoretical paradigms have a considerable impact on which issues and factors are given scholarly attention and which are not. In American family studies, the dominance of Talcott Parsons's (1943) theory of kinship in modern societies, which was part of his overall structural-functionalist model, may have contributed to the relative scarcity of attention to parental loss and its impact on adults. Parsons posited that at the time of marriage, it is most functional for adults in modern societies to largely disconnect from their parents and to focus on their own relatively autonomous nuclear households ( Parsons, 1943). Parsons's theory about adult autonomy from parents also was congruent with the dominant developmental theory of his period- Freudianism-which also emphasized the importance of autonomy from parents for healthy adults ( Freud, 1920/1965). However, contrary to supporting what Parsonsian theory might predict, research in the United States during the past 40 years has refuted the idea that Americans radically disconnect from or abandon their parents, married or not ( Bengtson, Rosenthal, & Burton, 1990; Cooney & Uhlenberg, 1992; Eggebeen & Hogan, 1990; Rossi & Rossi, 1990; Shanas et al., 1968; Spitz & Logan, 1992).

Although coresidence with older parents is not very prevalent at any point in time in the United States, research guided by a life course approach to intergenerational relationships has demonstrated that significant contact and exchange with living parents continues for the vast majority of American adults throughout adulthood ( Rossi & Rossi, 1990). As families become more vertical (i.e., more typically comprising persons from three or more generations) and less horizontal (i.e., more typically comprising fewer persons from the same generation, such as siblings and cousins) in structure, continuing relations across generations and interdependency across generations is becoming even more common and important to adults ( Bengtson, 2001; Bengtson et al., 1990; Cooney & Uhlenberg, 1992; Eggebeen & Hogan, 1990; Rossi & Rossi, 1990), and relationship quality with adult parents continues to influence the well-being of adult children ( Amato & Afifi, 2006; Barnett, Kibria, Baruch, & Pleck, 1991; Barnett, Marshall, & Pleck, 1992; Umberson, 1992).

Mothers continue to provide a range of financial, emotional, and instrumental support to daughters and sons across the adult years ( Cooney & Uhlenberg, 1992; Eggebeen & Hogan, 1990; Rossi & Rossi, 1990). Beginning in early adulthood, there is also a considerable amount of reciprocity in the relationship-especially in emotional and instrumental support. It is only after mothers become relatively older-typically in their 60s or 70s-that adult children are more likely to provide more support to mothers than they continue to receive ( Rossi & Rossi, 1990). Thus, mothers often remain a critical social resource to daughters and sons through early adulthood and into middle age.

Fathers, too, have an important influence on women's and men's lives and through their multifaceted roles as care providers, companions, spouses to mothers, protectors, models, moral guides, teachers, and breadwinners in families ( Lamb, 1997b). Although there is controversy regarding whether biology predisposes women to be more optimally equipped for nurturant parenting than men ( Rossi, 1984), considerable research has suggested there is nothing about the biological makeup of fathers that prevents them from becoming a critical secondary (or even primary) attachment figure for infants ( Lamb, 1997a). Research has confirmed that most infants do become attached to their fathers ( Lamb, 1997a).

In recent years, the literature on caregiving for older parents has suggested that concepts from attachment theory may continue to be relevant for adults in relationship to their aging parents. Bowlby's (1969, 1973, 1979, 1980) theory of lifespan attachment emphasizes humans' intrinsic biosocial propensity to seek security through connection with others in the face of a challenging outside world environment. Attachment theory posits that in the early months of life, infants seek a feeling of security (which is also the basis for courage to explore the world) through a responsive, dependable affectional bond that is established with one primary person-the "primary attachment figure," who in most cultures has been the mother. Because of the importance of the attachment figure to the child, there is a considerable motivation by the child to "protect" the attachment figure.

Empirical work guided by attachment theory has confirmed that mothers tend to be the primary attachment figure for children but that, as noted previously, significant attachments have been found to also develop with fathers ( Lamb, 1997a). Furthermore, considerable empirical research has now confirmed that different mental models regarding attachment exist in adults as well as children ( Feeney & Noller, 1990; Hazan & Shaver, 1987; Simpson, 1990) and that these attachment models are associated with retrospective accounts of childhood relationships with mothers and fathers ( Hazan & Shaver, 1987).

Cicirreli (1983, 1991, 1993) has suggested that continued adult attachment may help to motivate care giving for parents-as adult daughters and sons seek to protect their primary attachment figures, in part, to help them maintain the sense of emotional security that comes from having attachment figures alive and available for support. Attachment theory might also lead us to hypothesize that continued adult attachment to parents would also lead to a decline in well-being on loss of a parent to death in adulthood. Adults who have two parents alive, and therefore who have two primary affectional/attachment bond figures alive in their lives, might be expected to have a well-being advantage in adulthood that has been previously underestimated.

A family life course perspective ( Bengtson & Allen, 1993) guides us to consider the importance of "linked lives" for influencing well-being across the life course ( Elder, 1998; Elder, Johnson, & Crosnoe, 2003). It also guides us to pay attention to important life transitions and the quality of lifelong histories with relational partners when considering the well-being impact of a life transition ( George, 1993).

Attachment bonds with mothers and fathers typically date from birth. Yet all intergenerational dyad bonds are not the same. Gender theorists like Chodorow (1978) have suggested that children are socialized from an early age to identify with their same-gender parent and thereby create somewhat more distance from the opposite-gender parent. We find this theoretical orientation validated by the empirical evidence that the mother-daughter intergenerational bond is characterized by the greatest closeness of all gender dyad generational bonds ( Fingerman, 2001; Hagestad, 1987; Rossi & Rossi, 1990) and that fathers and sons show evidence of complex relationships that involve more "sharing of a life world" than fathers and daughters do ( Nydegger & Mitteness, 1996). Mother-daughter patterns of closeness intensify with aging, as mothers and daughters assume together more of the responsibility for "kinkeeping"-that is, working to maintain and nurture ties to the generations below and above them ( Fingerman, 2001) as well as ties with horizontal kin members (e.g., spouse, siblings, cousins, brothers- and sisters-in-law).

Part of the responsibility for family ties includes the responsibility for caregiving for family members who are not able to take full care of themselves. Increasingly, contemporary older adults are not dying suddenly from acute illnesses (e.g., infections) but are instead experiencing longer periods of chronic disease and chronic disease management with functional limitations prior to death ( Pol & Thomas, 1992). This phenomenon has led to an increasing need for caregiving for older parents among contemporary cohorts of young and midlife adults. The 2003 Caregiving in the U.S. Study (2004) found that 21% of a national sample of adults indicated they were providing some degree of help to a person more than 18 years of age who had some functional limitation; more than one third of caregivers in this study noted providing caregiving support to a parent (28% to a mother, 8% to a father).

Overall, women tend to assume a caregiving role for a parent more than men (Caregiving in the U.S., 2004; Marks, 1996a; Stone, Cafferata, & Sangl, 1987), and women doing family caregiving tend to report greater problematic effects in this role ( Yee & Schulz, 2000). Research suggests these gendered effects are likely due to the fact that caregiving women tend to be exposed to greater caregiving demands (e.g., spending more lime on caregiving, helping with more intense day-to-day tasks and personal care), they are more likely to be the primary caregiver and experience more role stains in combining the caregiver role with other roles, they receive less informal assistance in care giving from others, and they are less likely to engage in preventive health behaviors than comparable caregiving men ( Yee & Schulz, 2000). There does seem some same-gender preference in caregiving ( Lee, Dwyer, & Coward, 1993), such that if a father needs care, a son may be enlisted in caregiving. We might expect that many adult children who lose a parent to death have participated in some challenging caregiving close to the time of death, and this factor, too, may contribute to the negative effects on mental and physical health that we might expect derive from the loss of a parent to death.

The life course perspective also emphasizes the importance of "generational time" as a factor in development and well-being ( Bengtson & Allen, 1993). Generational time refers to one's lineage placement and how this connects with responsibilities, entitlements, developmental challenges, and developmental constraints. In the case of parent death, a major transition in generational placement occurs: An adult child often must transition to becoming the standard bearer for the family as the "oldest" generation in the family, and with the assumption of this new generational role comes additional responsibilities to family members that might previously have accrued to the parental generation ( Petersen & Rafuls, 1998). We might expect that the experience of generational transition may be most acute when a same-gender parent dies.

There is some related additional evidence suggesting that adult children experience a sense of their own aging and potential challenges of aging in watching their parents' changing health. Rakowski, Barber, and Seelbach (1983) found that young adult respondents who rated the health of their parents more poorly were also found to report greater anxiety about their own aging and less positive views of friends' and peers' aging. In a related vein, Barrett (2003) found that adults who rated their parents' health more poorly reported older subjective age identities than adults who rated their parents' health more favorably. Therefore, we might also expect that watching a parent or parents die might also affect adults' well-being through its impact on increasing concerns about their own aging and health. This impact might be especially acute in the case of a same-gender parent, where identification is strongest. Moving into the role of generational leadership for the family (along with the loss of former support and leadership this also implies) may also be accompanied by increased concern and stress and lead to problematic effects on well-being for individuals losing a parent (or parents) to death.

Psychological Well-Being and Physical Health Status as Multidimensional Constructs

Psychological well-being has increasingly been conceptualized and operationalized as a multidimensional construct, including both hedonic components and eudaimonic components ( Keyes, Shmotkin, & Ryff, 2002; Ryan & Deci, 2001). Hedonic approaches to conceptualizing well-being emphasize well-being to be a state in which individuals experience maximum amounts of pleasure and minimal levels of pain ( Kahneman, Diener, & Schwarz, 1999), whereas eudaimonic approaches conceptualize well-being, as live actualization of human potentials and optimal psychosocial functioning and engagement with life ( Waterman, 1993).

Assessments of negative affect (e.g., psychological distress) and positive affect (e.g., global happiness) are the most common operationalizations of hedonic well-being. Assessments of self-evaluation (e.g., self-esteem, personal mastery) and other adult development theory-derived outcomes articulated by Ryff (1989; e.g., personal growth, purpose in life, environmental mastery, autonomy, positive relations with others, self-acceptance) are the most typically considered eudaimonic outcomes examined.

Although alcohol abuse has not been typically included in psychologists' psychometric evaluations and conceptualizations of dimensions of psychological well-being, there has been increased use of measures of alcohol use as an alternative "functional equivalent" measure of psychological distress, with the rationale that this measure may better measure psychological distress for men than typical inventories of depression symptoms (e.g., Simon, 2002; Umberson & Chen, 1994).

Similar to psychological well-being, physical health status has been found to be usefully considered as a multidimensional construct, including related yet distinct dimensions of health perceptions, functional status, symptoms and diseases, mortality, and opportunities for activity ( Patrick & Bergner, 1990; Patrick & Erikson, 1993). Health perceptions (most typically measured by a single item for self-assessed health) have been found to be a particularly robust and important dimension of physical health. Across numerous studies and countries, self-assessed health has been found to be an important predictor of mortality, even above and beyond physician's reports of health ( Idler & Benyamini, 1997).

In this study, given the relative scarcity of research on the impact of parental death on adult children, we took an expansive approach to examining well-being outcomes. We investigated both hedonic well-being (depressive symptoms and happiness) and eudaimonic well-being (self-esteem, personal mastery, and psychological wellness-a composite measure of Ryff's eudaimonic well-being scales). We evaluated self-assessed health as an important dimension of physical health status. We also included a measure of binge drinking to evaluate an alternative pathway of expression for psychological distress (or negative affect), which might be particularly relevant for men.

Empirical Background

The few scholars who have examined parent loss and adult well-being have provided evidence that parental death is associated with some negative effects. Most of the literature on this topic is clinically based, using small nonrepresentative samples of persons who are recruited for study only after a parent loss has occurred. The clinical literature that has examined this issue has suggested that grief reactions after a parent's death can lead to depression, thoughts of suicide, and other psychiatric problems ( Birtchnell, 1975; Horowitz et al., 1981; McHorney & Mor, 1988; Sanders, 1979-1980).

Moving beyond a clinical approach, Scharlach (1991) examined initial and residual grief reactions among a convenience sample of 220 adults, ages 36 to 60, recruited through a notice in The Los Angeles Times, who experienced the death of a parent within the past 5 years. His results suggested that bereaved adult children report a wide range of initial symptoms related to parent death, including difficulties sleeping and working and getting along with certain people; residual reactions included becoming upset when thinking about the parent, finding it painful to recall the parent's memory, inability to avoid thinking about the parent, and crying when thinking about the parent. Sharlach did hot find differences in initial or residual grief reactions to mothers in contrast to fathers.

Moss, Moss, Rubinstein, and Resch (1993) evaluated responses from 102 daughters 40 to 65 years old who had recently experienced the death of a mother. They found substantial evidence of depression, grief, and somatic reactions, but they also found considerable heterogeneity in responses that was associated with differential characteristics of the daughter, mother, and quality of their relationship. In additional research, Moss, Resch, and Moss (1997) examined gender differences in response to death of a last surviving parent and found that overall, daughters reported more upset and somatic responses than sons.

The only previous prospective population study of psychological and physical health outcomes associated with parental death was undertaken by Umberson and Chen (1994), who used a U.S. national sample study (Americans' Changing Lives) to examine parent loss during a 3-year survey interval. These researchers found that loss of a mother (in contrast to no such loss) was associated with a greater increase in psychological distress over time for daughters and sons, although additional moderator analyses suggested this effect was not global across all subgroups. Specifically, sons who lost functionally impaired mothers to death experienced more increase in distress than sons who lost unimpaired mothers, whereas daughters whose unimpaired mothers died experienced more increase in distress than daughters who lost impaired mothers to death. Sons who recalled mental health problems of fathers in childhood also reported a greater increase in psychological distress on the death of a father than did other sons or daughters.

In terms of alcohol consumption (measured as number of drinks), Umberson and Chen (1994) found that father's death was associated with a greater increase in alcohol consumption over a period of 3 years than not experiencing a father's death-particularly among daughters who recalled family violence or who continued frequent contact with fathers and sons who recalled a father's drinking problem in childhood. These scholars also found evidence that the death of either a father or mother (in contrast to not experiencing a parent death) contributed to a greater decline in ratings of physical health over time across the entire sample of men and women.

Umberson (2003) also followed up this quantitative research with qualitative interviews of persons who had experienced the loss of a parent. These interviews are even more striking in providing evidence of the major life change that a parental loss can provoke. Most of the people she interviewed spoke about how dramatic this change was and how those who had not experienced this yet just did not understand what they were going through. Respondents remarked on how little place has been made for expression of filial grief in contemporary American society (a theme also replicated in Klapper, Moss, Moss, & Rubinstein's 1994 study of parental death). The qualitative analyses of Umberson's interviews also revealed how the general societal underestimation of the impact of filial bereavement may also lead to marital misunderstanding and marital problems, which has been confirmed by other quantitative analyses on this topic by Umberson (1995).

In this study, we aimed to build on previous clinical work and particularly extend the suggestive population study work of Umberson and Chen (1994) to further examine die issue of parent death and adult well-being. We expanded on Umberson and Chen's study in a number of ways. First, as noted previously, we examined a larger range of psychological well-being outcomes, adding an examination of measures of happiness, self-esteem, personal mastery, and psychological wellness, while including also, as they did, assessments of depressive symptoms (psychological distress), alcohol use, and self-assessed physical health.

Second, we examined as a separate category the well-being impact of losing both parents during a 5-year period. Finally, we added an examination of differences in tire well-being profiles of adults who went through a 5-year adult period with one or both parents dead (but who did not experience additional parent loss during the period) in contrast to adults who continued to have both parents alive during the same period of time.

In sum, our research objectives for this study were to address gaps in the aging and bereavement literatures on parent loss in adulthood and its effects on adult mental and physical health by (a) examining the impact of the loss of either a mother or father, or both, on multiple dimensions of psychological well-being, alcohol abuse, and self-assessed health, and (b) examining gender differences in the effects of parent loss on well-being.

Given typically strong life course attachment ties to both mothers and fathers, we expected that the death of a parent-mother or father, or both, as well as living without one or both parents (in contrast to having both parents alive)-would have a problematic impact on tire psychological and physical well-being of an adult child. Because of the particular closeness and identification associated with same-gender intergenerational dyads, we expected that death of mothers would be associated with more negative impact on well-being outcomes (other than binge drinking) for women in contrast to men and that death of fathers would be associated with more negative impact on well-being outcomes for men in contrast to women.

Given that death of both parents might be expected to particularly place women in a "kinkeeping" role for the entire family, we expected death of both parents to have a more negative impact on the well-being outcomes (other than binge drinking) of women than men. Likewise, given women's heightened socialization to be responsible for family relationships and attuned to family relationships for their sense of self and well-being ( Gilligan, 1982), we expected that women who continuously experienced life during a period of 5 adult years with one or both parents dead (in contrast to having both parents alive) would also experience poorer well-being outcomes (other than binge drinking) than their male peers. Because of previous evidence that alcohol use may be a more sensitive indicator of psychological distress for men than women (e.g., Simon, 2002), we expected loss of one or both parents or living without one or both parents alive (in contrast to having both parents alive) for 5 years would be associated with more binge drinking for men than women.

Method

Data

The data for these analyses came from the first and second waves of the National Survey of Families and Households (NSFH), which includes information from personal interviews conducted in 1987 and 1988 (Time 1, or T1) and in 1992 and 1993 (Time 2, or T2; 5 years later), with a nationally.-representative sample of 13,007 noninstitutionalized American adults, 19 years old and older (because of random sampling in households, a few participants less than 19 years old became primary respondents). This survey included a main sample of 9,643 respondents, with an additional oversample of 3,374 African Americans, Mexican Americans, Puerto Ricans, single parents, stepparents, cohabitors, and recently married persons. The response rate at T1 (1987 and 1988) was 75%. At T2 "(1992 and 1993), the reinterview response rate was 82% of first-wave respondents. This yielded national population coverage at a rate of about 62% (.74 ×.82) for data from both waves. Sampling weights correcting for selection probabilities and nonresponse allow this sample to match the composition of the U.S. population on age, sex, and race (see Sweet & Bumpass, 1996; Sweet, Bumpass, & Call, 1988, for more NSFH design details).

The analytic sample for this study consisted of NSFH primary respondents of all ages in 1987 and 1988, who also responded in 1992 and 1993 and who had complete and consistent information about whether their biological or adoptive mothers and fathers were alive or not at both T1 and T2 ( N= 8,865; 5,459 women, 3,406 men).

Measures

Parent status

Parent status contrasts were classified into five mutually exclusive and exhaustive categories based on respondent reports at both T1 and T2 about whether their mother and father were alive or deceased (see Table 1 ). Respondents who reported both parents alive at both T1 and T2 were classified as "both alive T1-T2" and used as the reference category in all analyses, respondents who reported their father was alive at T1 but dead at T2 were classified as "father died T2," respondents who reported their mother was alive at T1 but dead at T2 were classified as "mother died T2," respondents who reported both parents alive at T1 but reported both parents dead at T2 were classified as "both parents died T2," and respondents who reported either one parent dead or both parents dead at both T1 and T2 (but no change in death status between waves) were classified as "one or both parents dead T1-T2."

Table 1

Total Sample

Women

Men

Parent Status

Unweighted N

Weighted %

Unweighted N

Weighted %

Unweighted N

Weighted %

Well-being outcomes

For assessment of negative affect (psychological distress), we used a 12-item modified version of the Center for Epidemiological Studies Depression (CES-D) index ( Radloff, 1977) included at both waves to assess depressive symptoms (e.g., "On how many days during tire past week did you feel sad?" T1 and T2 alpha =.93). The logged score of the summed symptom score plus a constant of 1 was used for this measure to help correct for skew to the right (see Table 2 for descriptives for all analytic measures).

Table 2

Variable

M

SD

Range

Cronbach's Alpha

Mental and Physical Health Outcomes

Demographic characteristics

Gender ( female = 1)

0.53

0.50

0 to 1

Race/ethnicity ( non-White =1)

0.17

0.38

0 to 1

Optimal alcohol use is often considered to take a J-curve function-that is, zero consumption is considered potentially somewhat less beneficial than one to two drinks per day, yet binge drinking on any given occasion is always considered problematic. Therefore, we employed a dichotomous measure of binge drinking as an additional indicator of psychological distress in this study. Respondents atT2 of the NSFH were asked, "Have you had any alcoholic drinks during the past 30 days?" If they answered "yes," they were also queried, "On about how many days did you have five or more drinks on the same occasion during the past 30 days?" If respondents answered one or more to this question, they were coded 1 on binge drinking; respondents answering 0 were coded 0.

Positive affect was assessed with a one-item standard assessment of global happiness asked at both T1 and T2, "Taking things all together, how would you say things are these days?" (1 = very unhappy; 7 = very happy).

Two assessments of self-evaluation were included. Self-esteem was assessed with a three-item version of Rosenberg's (1965) self-esteem index (e.g., "On the whole I am satisfied with myself" [1 = strongly disagree; 5 = strongly agree]; T1 and T2 alpha = .63). We also evaluated a five-item personal mastery index consisting of four items from the Pearlin Mastery Scale ( Pearlin, Lieberman, Menaghan, & Mullan, 1981; e.g., "I can do just about anything I really set my mind to" [1 = strongly disagree; 5 = strongly agree]) along with a single item of control/mastery also assessed at T1 of the NSFH ("I have always felt pretty sure my life would work out the way I wanted it to"; T2 alpha = .64).

To evaluate psychological wellness, we used an 18-item version of Ryff's psychological wellness assessment ( Ryff, 1989; Ryff & Keyes, 1995), which includes three items from each of Ryff's six scales (all rated 1 = strongly disagree; 5 = strongly agree) assessing autonomy (e.g., "I judge myself by what I think is important, not by the values of what others think is important"), personal growth (e.g., "For me, life has been a continuous process of learning, changing, and growth"), positive relations with others (e.g., "People would describe me as a giving person, willing to share my time with others"), purpose in life (e.g., "Some people wander aimlessly through life, but I am not one of them"), and self-acceptance (e.g., "When I look at the story of my life, I am pleased how things have turned out"). Cronbach's alpha for the 18-item scale was .81.

Global self-assessed health was assessed with a standard one-item measure of health: "Compared to other people your age, how would you describe your health?" (1 = very poor; 5 = excellent).

For four measures-the CES-D, global happiness, self-esteem, and global health-T1 assessment of the measures were available and were controlled in the respective analyses. For the Personal Mastery Scale, responses to the one item measuring personal mastery that was included at T1 of the NSFH was included as a T1 control (the correlation of this one item at T2 with the other four items of the scale at T2 is .32). The binge drinking assessment and the Ryff measure were not included at T1, so the CES-D assessment from T1 was entered to help control for T1 well-being in all analyses of these measures to better estimate the likely longitudinal change in well-being over time because of loss of parents.

Several demographic statuses-gender, age, race/ethnicity, education, household income, parental status, and employment status-were controlled in all analyses because they are associated with psychological and physical health ( Ross, Mirowsky, & Goldsteen, 1990) and might have confounded our results. Demographic variables were constructed as follows: gender (1 = female), age (T1, in years), race/ethnicity (coded 1 = non-White vs. 0 = non-Hispanic White), education (T2, in years), household income (continuous measure totaled across all types of earned and unearned income for all household members at T2; respondents missing on income were coded -1 on this continuous variable and maintained in the analyses by simultaneously including a dichotomous "missing on T2 household income" flag variable in all the models), missing on T2 household income (dichotomous flag variable to include all respondents missing on income in the regression analyses, missing T2 household income = 1; not missing T2 household income = 0), having a child age 18 or younger in the household at T2 (1 = has child; 0 = no child), and employment status at T2 (1 = employed; 0 = not employed).

Analytic Sequence

Multivariate Ordinary Least Squares (OLS) or logit regression models were estimated for all analyses using Statistical Package for the Social Sciences. Preliminary analyses included both men and women in models that included gender interaction variables. Specifically, each of the outcomes was regressed on gender, all of the other demographic control variables, the parent status variables, and gender by parent status interaction variables. For five of the seven outcomes, at least one significant gender interaction was found. Therefore, final models were estimated separately for men and women. Models were estimated with both weighted data and unweighted data. The pattern of estimates was relatively similar across both sets of models, and therefore, we report results from the unweighted data where standard errors are expected to be more reliable ( Winship & Radbill, 1994).

Results

Gender Differences in Effects of Parent Death on Adults

To test our gender difference hypotheses, we estimated models with gender interactions as noted above (full results not shown; significant gender interactions noted on Table 3 ). Consistent with our hypothesis that loss of a same-gender parent would be associated with greater negative effects (except for mother loss for women on binge drinking), we found that loss of a father led to a significantly greater increase in depressive symptoms for men in contrast to women (Female × Father Died, b = −0.20, p ≤ .05). Additionally, loss of father was associated with a trend toward lower levels of psychological wellness for men in contrast to women (Female × Father Died, b = 1.34, p ≤ .10).

Table 3

Depressive symptomsc

Binge Drinkingd

Global Happinessc

Self-Esteemc

Personal Masteryc

Psychological Wellnessc

Self-Assessed Physical Healthc

Variable

Women

Men

Women

Men

Women

Men

Women

Men

Women

Men

Women

Men

Women

Men

Both alive T1-T2
(omitted)

-

-

1.00

1.00

-

-

-

-

-

-

-

-

-

-

Father died T2

−0.01 a
(.06)

1.11
(.20)

0.91
(.17)

−0.04
(.08)

0.03
(.10)

−0.01
(.03)

−0.05 †
(.04)

−0.42**
(.18)

−0.38*
(.22)

−0.04
(.04)

−0.06
(.05)

Mother died T2

0.07
(.06)

0.08
(.08)

1.42*
(.21)

1.26
(.19)

−0.12 †
(.09)

−0.22*
(.11)

−0.09**
(.04)

−0.03
(.04)

−0.46**
(.19)

−0.27
(.24)

−1.12*
(.67)

−1.92*
(.88)

−0.06
(.05)

−0.14**
(.06)

Both parents diedT2

0.31*
(.15)

0.11
(.20)

1.40
(.49)

2.67**
(.45)

0.12 a
(.25)

−0.21**
(.09)

−0.34***
(.11)

−1.09**
(.47)

−1.37**
(.60)

−3.63**
(1.56)

−4.72**
(2.14)

−0.10 b
(.11)

One or both dead T1-T2

0.07*
(.04)

0.07 †
(.05)

1.12
(.14)

0.92
(.11)

−0.01 a
(.07)

−0.05*
(.02)

−0.04 †
(.03)

−0.05 a
(.15)

−1.06**
(.44)

−0.44
(.53)

−0.04 †
(.03)

−0.10**
(.03)

Time 1 variables

Depressive symptoms

0.38***
(.01)

0.34***
(.02)

1.04
(.05)

1.07*
(.04)

−2.15***
(.14)

−2.04***
(.17)

Global happiness

0.24***
(.02)

0.23***
(.02)

Self-esteem

0.35***
(.02)

0.33***
(.02)

Personal mastery

0.73***
(.05)

0.74***
(.06)

Self-assessed health

0.49***
(.01)

0.41***
(.02)

R ²
.19

.17

.09

.09

.15

.16

.12

.11

.14

.11

.28

.24

−2LL

2,625.14

3,188.31

df
14

14

Change in R ² e

.001

.002

.002*

.002

.002*

.003*

.003*

.003 †

.002*

.004*

.000

.004***

Change in −2LL f

−2.99

−7.94 †

Consistent with our hypothesis that loss of both parents would be associated with more negative effects for women than for men, we found that loss of both parents was associated with a greater decrease in positive affect (happiness) for women in contrast to men (Female × Both Parents Died, b = −0.61, p ≤ .05). Also, as predicted, having one or both parents dead across this entire 5-year period, in contrast to having both parents alive, was associated with a greater decline in global happiness among women (Female × One or Both Dead T1-T2, b = −0.12, p ≤ .05) and lower reported levels of personal mastery among women (Female × One or Both Dead T1-T2, b = −0.32, p ≤ .05).

Contrary to our hypothesis, loss of both parents was associated with a trend toward a greater decrease in self-assessed health for men in contrast to women (Female × Both Parents Died, b = 0.24, p ≤ .10).

Overall, these results were somewhat supportive of our hypotheses, although it is also important to note that many hypothesized gender differences did not emerge in the gender-combined analyses. Our findings do suggest that it is valuable to evaluate multiple dimensions of mental and physical well-being to get a more complete understanding of gender differences in the impact of death of parents.

Effects of Parent Loss on Psychological and Physical Well-Being for Daughters and Sons Considered Separately

Table 3 provides estimates from regression models estimated separately for women and men. These results provide us with a more detailed within-gender account of the effects of parent loss on mental and physical health. Although not absolutely consistent, our findings provide considerable support for our hypothesis that parent loss is associated with poorer psychological and physical well-being in comparison to continuing to have both parents alive.

Among women, loss of a father during a 5-year period (in contrast to continuing to have both parents remain alive) was associated with a lower level of personal mastery and a trend toward a lower level of psychological wellness. Among men, loss of father (their same-gender parent) was associated with even more problematic effects on psychological well-being-a greater increase m depressive symptoms, a lower level of personal mastery, a trend toward a greater decrease in self-esteem, and a lower level of psychological wellness.

Loss of a mother among women (their same-gender parent) was associated with greater odds of binge drinking, a trend toward a greater decline in global happiness, a greater decline in self-esteem, a lower level of personal mastery, and a lower level of psychological wellness. Men who reported loss of their mother also reported a greater decline in global happiness, a lower level of psychological wellness, and a greater decline in self-rated health than men who continued to have both parents alive.

Loss of both parents among women was associated with several significant negative effects, including a greater increase in depressive symptoms, a greater decline in happiness, a greater decline in self-esteem, a lower level of personal mastery, and a lower level of psychological wellness. Among men, loss of both parents led to greater odds of binge drinking, a greater decline in self-esteem, a lower level of personal mastery, a lower level of psychological wellness, and a greater decline in self-rated health.

It is interesting that our additional contrast of persons who did not have a new loss during the 5-year interval but who continued life with one or both parents dead in contrast to having both parents alive during a period of 5 adult years provided additional support for the hypothesis that having both parents alive is a well-being advantage for adults. Both women and men who had one or both parents dead reported a greater increase in depressive symptoms (trend-level effect for men), a greater decline in self-esteem (trend-level effect for men), and a greater decline in self-rated health (trend-level effect for women) during this 5-year period. Women in this parent loss status also reported a greater decline in global happiness, a lower level of personal mastery, and a lower level of psychological wellness.

Discussion

Guided by a life course perspective, attachment theory, and gender theory, this study aimed to examine the impact of the death of parents on multiple dimensions of psychological well-being as well as self-assessed health among adults and to examine gender differences in the effects of parent loss on well-being. We hypothesized that loss of a father or mother or both as well as living with one or both parents dead during a 5-year period (in contrast to having both parents alive) would be associated with greater declines or lower levels of psychological and physical well-being. We also hypothesized that because of gender socialization to identify with the same-gender parent and intergenerational family relationship patterns, men would experience more problematic effects from death of a father on all well-being outcomes, and women would experience more problematic effects from death of a mother, death of both parents, or life without both parents alive on well-being outcomes other than binge drinking. We expected any type of loss of parents studied to lead to a more problematic impact on binge drinking for men than women.

Overall, we found considerable evidence supporting the idea that because of long-term linked lives across time and because of the typically strong affectional bonds and attachment experienced with mothers and fathers, the death of a mother or father or both in adulthood is associated with a number of negative effects on mental and physical well-being. We also found partial support for our gender hypotheses. Between-gender and within-gender analyses across multiple dimensions of well-being allowed us to see that the effects of loss came through in somewhat different ways for women and men.

Specifically, our results suggest that death of a father may have a more negative effect on sons in contrast to daughters. Death of a father led to less personal mastery for both daughters and sons. But loss of a father was also associated with a greater increase in depressive symptoms and lower psychological wellness for sons.

Our results also suggest that death of a mother may have somewhat more problematic effects on daughters in contrast to sons. Death of a mother was associated with lower levels of psychological wellness for both daughters and sons. But loss of a mother for daughters was also associated with greater odds of binge chinking, a greater decline in self-esteem, and a lower level of personal mastery. Loss of a mother was also associated with a greater decline in happiness for sons.

Death of both parents within a 5-year period is not exceptionally common, but it still occurs frequently enough to take seriously (about 1 out of every 100 of our national respondents experienced this sequence of events during a 5-year period). We predicted that loss of both parents would be more problematic for women than for men; however, death of both parents was associated with negative effects for both daughters and sons relatively equally. Both daughters and sons experiencing the death of both parents reported greater declines in self-esteem, lower levels of mastery, and lower levels of psychological wellness. Daughters additionally reported a greater increase in depressive symptoms and a greater decline in happiness. Sons additionally reported significantly higher odds of binge drinking and a greater decline in health.

A new contribution of this study is our finding that living 5 adult years with one or both parents dead in contrast to having both parents alive is associated with poorer well-being outcomes liven without having experienced a recent parent loss, women with one or both parents dead reported a greater increase in depressive symptoms, a greater decline in global happiness, a greater decline in self-esteem, a lower level of personal mastery, and a lower level of psychological wellness when contrasted with their women peers who continued to have both parents alive during the 5-year period studied.

Among men, the most robust evidence of the well-being impact of having one or both parents dead in contrast to having both alive came through their reports of a greater decline in self-assessed physical health over 5 years (in contrast to their male peers who had both parents alive). Overall, our results suggest that having one or both parents dead in contrast to having both parents alive is associated with generally poorer psychological well-being over time for women and poorer physical health over time for men. This pattern of findings also supported our hypothesis that having one or both parents dead would be more problematic for the well-being of daughters in contrast to sons.

Our results are partly congruent with those of Umberson and Chen (1994), who did a somewhat similar analysis across a 3-year timeframe. Similar to their results, we also found that loss of a mother led to a greater decline in sons' health over time. However, we did not find the same association between loss of father and greater increase in alcohol consumption as measured by number of drinks. By contrast, we used a measure of binge drinking and found that it was loss of mother that led to more binge drinking among women (contrary to expectation) and loss of both parents that led to more binge drinking among men. In subgroup analyses, Umberson and Chen found that it was mainly certain subgroups of men that experienced a greater increase in psychological distress over time because of a loss of mother. We found that living with one or both parents dead (in contrast to living with both parents alive) or having both parents die led to a greater increase in psychological distress for women and that loss of father led to a greater increase in psychological distress for men.

The inconsistency in our results may be due to the fact that we had a slightly different timeframe for analysis-3 versus 5 years. Additionally, we set up our contrast groups somewhat differently (we included a "both parents died" group and used "both parents alive" as the reference group). Our measure of alcohol consumption was also different-emphasizing binge drinking in contrast to a linear number of chinks. Umberson and Chen (1994) also looked at various two-way and three-way interactions across subgroups. We emphasized particularly an examination of gender differences and within-group differences within gender. But both of our analyses lead to similar conclusions overall-that there are negative mental and physical effects over time for adults because of death of parents.

Both these national studies also give credence to what smaller studies with more limited samples have indicated-parent loss is associated with problematic outcomes, sometimes short term and sometimes long term, and should not be underestimated ( Birtchnell, 1975; Horowitz et al., 1981; McHorney & Mor, 1988; Moss et al, 1993; Sanders, 1979-1980; Scharlach, 1991).

Our study is limited in not taking into account the numerous life course relationship quality factors and sociodemographic factors that we might expect may further modify effects of parent loss on well-being. We note that Umberson and Chen examined 14 such factors, in addition to gender-both for two-way interactions and three-way interactions with gender-and found only three factors modifying effects on psychological distress (modier's functional health for mother's death, father's drinking problem, and father's mental health in childhood for father's death). Only mother's violent behavior modified effects of mother's death on alcohol consumption; age, marital status, emotional support from father, father's drinking, and frequency of contact with father modified effects of father's death on alcohol consumption. None of the factors studied by Umberson and Chen modified the effects of mother's or father's death on physical health. Therefore, although it is important to further consider these subgroup differences, there is also evidence to suggest that the problematic impact of parent death on psychological and physical well-being is not limited to only a few specific groups.

We also acknowledge that because of a 5-year gap in time, we may be missing some of the shorter term negative effects for persons who lost a parent 2 to 5 years prior to their second reports. But the fact that we still find the negative effects we do in this population-level analysis, even when we may be underestimating shorter term negative effects (e.g., within 2 years of a loss), further suggests the robustness of the negative effects on psychological and physical health reported here.

Implications for Research on Aging Families and for Practitioners

The results from this study have important implications for research on aging families. Our finding of numerous problematic effects of parent death for adult children suggests the need to continue population as well as more in-depth studies that inquire into how relationships with parents, experiencing and attending to the physical demise of parents, and the loss of parents to death affect the mental and physical health of adults. We speculated about some processes-for example, generational succession, prior caregiving, images of aging, grief because of attachment, and loss of an important emotional and instrumental support person-that might be contributing to the problematic effects of parent loss on well-being that we found. However, additional research is necessary to further explore which processes and mechanisms truly are operative in these associations.

Our finding of poorer well-being among adults who had experienced one or two parent losses prior to the study suggests that additional research should explore how availability of mothers and fathers continues to be a factor in helping shape adult children's mental and physical well-being profiles. Lower socioeconomic status adults lose their mothers and fathers to death earlier than higher socioeconomic status adults ( Marks, 1996b). Availability of parent support in adulthood may be one of the unexplored social factors that helps reproduce persistent social inequalities in health ( Adler, Boyce, Chesney, Folkman, & Syme, 1993).

Future research should also further examine additional factors, such as differences in past and recent relationship quality, differences in culture, and differences in other sociodemographic factors, that may moderate the relationships between parent loss and well-being. Beyond preloss factors that may moderate the associations between loss and well-being, it is also important for future research to consider postloss factors that can help attenuate the impact of parent loss on well-being.

Gender was found to be an important moderator of the impact of parent loss. Future research investigating further why the loss of a same-gender parent is most problematic for adult well-being would also be very valuable. Likewise, exploring additional physical health outcomes would be helpful to evaluate whether the greater impact of parent loss on physical health for men than women we found in some cases is a consistent pattern across other dimensions of physical health.

The results from this study also have several implications for family life educators, clinical psychologists, marriage and family therapists, and other practitioners working with adults. First, it appears time to fully recognize the importance of addressing the significance of parent loss for adults in family life education and practitioner education and training. Family life educators should include attention to preparing adults to anticipate that the loss of a parent or parents may not be an easy transition. It would be helpful if adults were allowed to understand that they are not abnormal if they experience a challenging time with these losses. Although it is relatively expectable to lose parents to death during adulthood, because of the long-term attachments and linked lives associated with the mother-adult child bond and the father-adult child bond, it is not uncommon for the death of a parent to be a psychologically and physically challenging as well as a potentially transformative event ( Umberson, 2003).

Given the evidence that parent loss can also affect marital interactions and marital quality ( Umberson, 1995, 2003), it is also important that those doing counseling with couples be cognizant of the potential issues between couples that may emerge when one member of the couple loses a parent to death. Once again, because of a societal minimizing of this loss, a marital partner may inappropriately feel their bereaved partner should "just get over it" and may deride or misunderstand the grieved partner, unless there is better overall understanding of the depth of this loss.

Filial bereavement may also spill over into how an adult may continue to care for their own children, particularly if these children are still young. The death of an adult's parent means that the children of that adult have also lost a grandparent. Therefore, it may be advisable that such a death be considered and supported by family life educators and practitioners in a holistic family systems fashion ( Abeles, Victor, & Delano-Wood, 2004).

It is clear from this study that parental death has an important impact on adults' psychological and physical well-being and that this impact varies by gender. Additional research attention to this topic is important to help further illuminate the many ways in which parent-child relationships continue to be an important factor in determining well-being for both parents and adult children across the adult life course. Additional practitioner attention is important to help adult children, their partners, and their families traverse as positively as possible the life course experience of the death of parents.

Acknowledgments

Support for this research was provided by the John D. and Catherine T. MacArthur Foundation Research Network on Successful Midlife Development, the National Institute on Aging (AG12731, AG206983), and the National Institute on Mental Health (MH61083).

Contributor Information

Nadine F. Marks, University of Wisconsin-Madison.

Heyjung Jun, Yonsei University, Seoul, Korea.

Jieun Song, University of Wisconsin-Madison.

References

Sweet JA, Bumpass LL. The National Survey of Families and Households Waves 1 and 2: Data description and documentation. Madison: Center for Demography and Ecology, University of Wisconsin-Madison; 1996. Available at [http://www.ssc.wisc.edu/nsfliyhome.htm. Google Scholar]

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Death of Parents and Adult Psychological and Physical Well-Being: A Prospective U.S. National Study

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Guided by a life course perspective, attachment theory, and gender theory, this study aims to examine the impact of death of a father, a mother, or both parents, as well as continuously living with one or both parents dead (in contrast to having two parents ...

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Fathers are always more protective about their daughters. They always have a fear of losing them to some other man. They make sure no harm ever comes to their little butterfly. They know how men are both good and bad. They are protective that neither a good man shall love them more than him nor a bad man shall harm them at any cost. A father is always protective towards their daughter as compared to their son.

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"No man can ever love her as much as he does." All the girls would agree to this. If sons are close to their mother, daughters are the closest to their father. No man can ever beat the love of a father for his daughter.

Anyone can become a father, but it takes the soul to be a real father. One cannot just be a father without taking up the paternal responsibilities.

The pain of bringing up their girls for years and after nurturing them like a baby plant, someone else claims to love them and takes them away for the rest of the life.

This article will fall short of why a daughter is always going to be the most precious thing for a father, but to make your Father's Day week special, we have brought together the most important and relevant reasons which every daughter can relate to.

Let's see what are those reasons that make daughters the closest to their father:

Father And Daughter Bonding

Yes, while sons are the mother's adorable ones, daughters are always going to rule father's hearts. It is always said that the opposites match, yes it follows here too. Fathers are more inclined towards their daughters and daughters are always inclined towards their fathers because of the same.

Protection Level

Fathers are always more protective about their daughters. They always have a fear of losing them to some other man. They make sure no harm ever comes to their little butterfly. They know how men are both good and bad. They are protective that neither a good man shall love them more than him nor a bad man shall harm them at any cost. A father is always protective towards their daughter as compared to their son.

Daughters Are The Priceless Jewels

A daughter is always considered to be as the asset of the father. A father never takes anything from the daughters, rather keeps on giving her the entire life. A father always considers his daughter as the asset of the lifetime. No matter how rich or poor a dad is, but if he has a daughter, he always considers her a priceless jewel. No gold can beat the worth of a daughter.

Daughter's Marriage

Since the day a daughter is born to a father, he dreams of his daughter's marriage and giving her hand to someone else. Just imagine you nurture a daughter for years, consider as a piece of your heart and one day you have to give her away to someone else. Though every father dreams of it, still he is always afraid and sad to do it. What if he did not choose a good partner for her or what if he is not able to give her away to some other man.

What Is Home Without A Girl Child?

Not only fathers, but the entire family loves it when a girl is born. A girl in the family is not only a father's dearest but everyone's apple pie. Since the day a daughter is born, everyone is excited to nurture her, grow her up, educate her and then get her married. It becomes the entire family's dream to see her in the getup of a bride. A daughter is considered as the wealth of the house.

So Much Fun To Dress Up A Daughter

Everyone in the family is more excited to dress her up as soon as she is born. When a daughter is born to a father, the father is so much more excited that he will be shopping such fancy kinds of stuff for her. He is always excited to get her new things and clothes. Unlike sons, daughters are never boring to play with and dress up with.

Success Stories Of A Daughter Make Her Father Proud

Whenever a son achieves success, the father and the family is not as much happy and cheerful as much happy when their daughter achieves success. We all know that the son would probably do something or the other or help their father in the business, but it is the proudest moment for any father to show it off to the world that his daughter has achieved something. Not only the father, but everyone feels proud whenever the daughter makes a success.

Always Saving Father

A daughter plays the role of a referee between a father and a mother. Whenever parents feel that they are falling out of love, the daughter gives them a reason to love each other more. When a father and a mother divulge into an argument or fight, the daughter always saves the side of the father and becomes the referee.

Words will always fall short while defining a father-daughter relationship.

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Reasons Why Daughters Are The Closest To Their Father

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"No man can ever love her as much as he does." All the girls would agree to this. If sons are close to their mother, daughters are the closest to their father. No man can ever beat the love of a father for his daughter.

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Video

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Helping children understand death accurately is important in helping them cope with loss as they grow.

Download the New York Life Foundation guide.

Explaining death to children

Be gentle, but direct with the truth about death and dying.

Adults can help children by clearly explaining what happened using the words "death," "dead," and "died." Trying to soften the language, such as "they are no longer with us" leaves many children with lingering questions.

Children may only understand part of the explanation.

Many adults expect children to grieve the way adults would, and mistakenly think that kids are "fine" if they don't immediately show their emotions. It takes time for all of us to understand and process what death means. Asking the child to explain what they understand has happened is a good way to see where more explanation might be needed. The child might be afraid to ask for clarification, so it is best if the adult asks to see what the child understands.

Check-in with the child over time.

A child's understanding of grief grows and matures as they learn and grow. Realize that their grief may surface many times throughout their childhood and adolescence as they begin to understand different aspects of death and loss. Important milestones for the child may also trigger their grief, as they wish the loved one was there to experience it with them.

Grief experts share their insight regarding children's grief:

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Speaking Grief | Understanding Grief: Kids grieve differently than adults

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Helping children understand death accurately is important in helping them cope with loss as they grow. Be gentle, but direct with the truth about death and dying. Adults can help children by clearly explaining what happened using the words "death," "dead," and "died."

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This is a nonfiction book published by The National Library of Medicine.

estimates that 5 percent of children in the United States—1.5 million—lose one or both parents by age 15; others suggest that the proportion is substantially higher in lower socioeconomic groups

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DEVELOPMENTAL CONSIDERATIONS

Individuals continue to grow and develop throughout life, but during no other period beyond childhood and adolescence are specific reactions as likely to be influenced by the level of development. Because the impact of trauma in children depends so heavily on the life stage during which the event occurs, this chapter is informed by a particular emphasis on developmental analysis. This perspective assumes that the repercussions and meanings of major object loss will be colored by the individual child's level of development. Psychiatrists and others have generally been struck by how often major childhood loss seems to result in psychopathology. Studies of adults with various mental disorders, especially depression, frequently reveal childhood bereavement, suggesting that such loss may precipitate or contribute to the development of a variety of psychiatric disorders and that this experience can render a person emotionally vulnerable for life. This special vulnerability of children is attributed to developmental immaturity and insufficiently developed coping capacities.

The tendency to impose adult models on children has generally led to a great deal of confusion and misunderstanding about children's grieving. Although sharing some similarities with adults and even with monkeys (see Chapter 7), children's reactions to loss do not look exactly like adults' reactions, either in their specific manifestations or in their duration.

For example, often what seems glib and unemotional in the small child-such as telling every visitor or stranger on the street, "my sister died"-is the child's way of seeking support and observing others to gauge how he or she should feel. Children may be observed playing games in which the death or funeral activities are reenacted in an effort to master the loss. A child may ask the same questions about the death over and over again, not so much for the factual value of the information as for reassurance that the story has not changed. A four- or five-year-old might resume playing following a death as if nothing distressing had happened. Such behavior reflects the cognitive and emotional capacity of the child and does not mean that the death had no impact.

Losses are so painful and frightening that many young children-able to endure strong emotions for only brief periods-alternately approach and avoid their feelings so as not to be overwhelmed. Because these emotions may be expressed as angry outbursts or misbehavior, rather than as sadness, they may not be recognized as grief-related. Furthermore, because their needs to be cared for and related to are intense and immediate, young children typically move from grief reactions to a prompt search for and acceptance of replacement persons. Unlike adults who can sustain a year or more of intense grieving, children are likely to manifest grief-related affects and behavior, on an intermittent basis, for many years after loss occurs; various powerful reactions to the loss normally will be revived, reviewed and worked through repeatedly at successive levels of subsequent development. Thus, in dealing with chil dren who have sustained a loss it is important to be aware of the special nature of grieving in children and not to expect that they will express their emotions like adults or that their overt behaviors will necessarily reveal their internal distress. As noted later in this chapter, the delayed working through of bereavement may require specialized assistance if development seems blocked or psychopathologic symptoms appear.

In order for complete ''mourning" to occur in the true psychoanalytic sense of detaching memories and hopes from the dead person, , the child must have some understanding of the concept of death, be capable of forming a real attachment bond, and have a mental representation of the attachment figure. Although there is no doubt that even very young children react to loss, there is considerable controversy about when children have the developmental prerequisites for complete "mourning" and about the likelihood of achieving a healthy outcome if bereavement occurs prior to this time. Generally it is agreed that prior to age 3 or 4 children are not able to achieve complete mourning and it is agreed that by adolescence youngsters can mourn (but are still more vulnerable than adults because they are experiencing so many other losses and changes). The controversy centers on the years in between: can a healthy resolution be achieved and how similar are children's and adults' bereavement reactions?

A number of studies have been conducted in recent years (e.g., Anthony, Bluebond-Langer, Gibney, Kane, Koocher, MenigPeterson and McCabe, Piaget, Pitcher and Prelinger, Spinetta, Tallmer et al. ) to determine how children at various ages comprehend death.

A fairly standard view was put forth by Nagy in 1948. Analyzing the words and drawings of a relatively large sample (378) of Hungarian children who had been exposed to considerable trauma and death in the preceding few years, she conceptualized a three-stage model of awareness and linked the stages to approximate chronological ages.

Prior to about three years of age, children's cognitive and language development is too immature for them to have any concept of death. According to Nagy's stage 1 (roughly ages 3-5), death is seen as reversible; the dead are simply considered "less alive," in a state analogous to sleep. Young children functioning at what Piaget termed the "preoperational" level of development will not generally recognize the irreversibility of death. ,, In stage 2 (ages 5-9), children begin to comprehend the finality of death, but believe that it happens only to other people. In the third stage (after age 10), the causes of death can be understood, and death is perceived as final, inevitable, and associated with the cessation of bodily activities. As is true in all child development, there is considerable age variation in attainment of the different stages and children may regress when emotionally threatened.

Prior to about six months of age, infants fail to respond to separation from their mothers because they have not yet developed the capacity for memory of a specific personal relationship. The development of stranger anxiety, occurring at about six to eight months, signifies that an infant has established a true object relationship with its mother or primary caretaking figure. This reaction suggests that an infant is developmentally capable of retaining memory traces of his mother and is capable of responding to her absence with displeasure and depression. However, it is not until three or four years of age that a child has a coherent mental representation of important attachment figures and has achieved object constancy.

Observational studies of children between about four years of age and adolescence have led psychiatrists to conflicting conclusions about the nature of children's grieving and about their ability to achieve a healthy outcome. Some psychoanalysts ,,,, maintain that it is not until adolescence that children have the capacity to tolerate the strong painful affects necessary for completing the separation process and that children are more likely to use immature defense mechanisms, such as denial, that interfere with adequate resolution of loss. Thus these observers view children's reactions to loss as qualitatively different from adult reactions.

Others believe that after object constancy has been achieved (at three to four years of age), bereavement need not necessarily lead to enduring psychopathology. Increasingly, it is being recognized ,, that if the child has a consistent adult who reliably satisfies reality needs and encourages the expression of feelings about the loss, healthy adjustment can occur. Furthermore, the biologic unfolding inherent in development naturally pushes children toward increasing cognitive and emotional maturity. This "developmental push" is seen as an asset that contributes to children's potential resiliency under favorable circumstances.

Some psychiatrists, most notably Bowlby, emphasize the similarities between adults' and children's responses to loss and see an evolutionary basis for them. In Bowlby's view, the argument about children's capacity for "mourning" is in large part terminological, with many psychoanalysts restricting the use of "mourning" to psychological processes with a single outcome-detachment-and others using it more broadly ''to denote a fairly wide array of psychological processes set in train by the loss of a loved person irrespective of outcome."

Kliman suggested at one of the committee's site visits that perhaps too much concern has focused on this debate. In his opinion it would be more fruitful to have a detailed understanding of the bereavement process in children so that those who interact with children can be most responsive and helpful.

METHODOLOGICAL ISSUES

Most of the literature on bereavement in childhood is based on observations of disturbed children who are in psychotherapeutic or psychoanalytic treatment. These case reports offer valuable clinical information regarding psychological symptoms and processes, but it is difficult to know the degree to which these children in treatment are representative of all bereaved children and the extent to which individual reactions may be idiosyncratic.

On the other hand, random samples of bereaved children that provide more methodologically reliable data do not offer the same depth of information. In addition, relatively few use control groups, making it impossible to know what the base rates of particular behaviors or symptoms might be in the general population. Where controls are used, it is often unclear whether they are matched for age and sex.

Most of the data on very early (below the age of five) childhood loss are not specific to bereavement but are based on observations of institutionalized children (e.g., Bowlby ⁻) who were temporarily separated from parents. It is not clear if the children's responses in these studies were based on parental loss itself, on the multiple other losses associated with removal from the home environment, or the unfamiliar and sometimes chaotic circumstances associated with institutional placement. Because these children were not followed over a very long period of time, neither is it known whether pathologic or disturbing reactions endured.

Studies of the long-term effects of bereavement during childhood are abundant, but they are highly controversial because they almost always rely on retrospective data (see Gregory for a discussion). In addition these studies often fail to consider the impact of intervening life events, rely too heavily on data based on patients' memories, and use inappropriate control groups.

A handful of prospective studies describe intermediate effects, but many of these have methodologic flaws, such as a failure to use nonbereaved control groups, , a lack of direct assessment of bereaved children, and a failure to follow children over a sufficiently long pe riod of time. , Furthermore, it is not clear that findings from studies conducted in other countries, possibly during wartime, can be generalized to American children living under less socially disruptive conditions. Different methods have been used to study outcomes of childhood bereavement and, partly because of the variation in approach, studies have yielded different results.

Few studies provide precise definitions of key terms, such as "depression, "exaggerated responses, " "pathologic grief, " "anger, '' and "sadness," so it is difficult to know whether all authors are referring to the same specific reactions. Studies on childhood loss tend to rely exclusively on interview data or material in case files; standardized instruments that permit greater generalization across studies have rarely been used in the assessment of children. In fact, such instruments have only begun to be developed in the past few years. It should be noted that, because of the way this chapter is organized, a number of studies are cited several times, perhaps giving the impression that there are more empirical data than is really the case.

OUTCOMES OF CHILDHOOD BEREAVEMENT

The death of a parent during childhood has been linked with a wide range of serious and enduring health consequences ranging from schizophrenia to major depression and suicide (see Table 1 for a summary of key findings from each of the major studies). The particular symptoms and syndromes associated with childhood bereavement are generally considered in terms of the immediate reactions that occur in the weeks and months following the death, the intermediate reactions that can appear later in childhood or adolescence, and the long-range or "sleeper" effects that may appear in adulthood either as enduring consequences or delayed reactions to the loss. Although these long-range effects are of most concern, the research evidence in this area is probably the weakest.

Immediate Reactions

Children, like adults, experience a range of emotional and behavioral reactions immediately following parental or sibling death. Studies of both patient and nonpatient samples report that children respond to loss with similar symptoms.

People who interact with recently bereaved children find them sad, angry, and fearful; their behavior includes appetite and sleep disturbances, withdrawal, concentration difficulties, dependency, regression, restlessness, and learning difficulties. They also note that initial symp tom patterns depend largely on the age at which the child is bereaved. For example, children under age five are likely to respond with eating, sleeping, and bowel and bladder disturbances; those under age two may show loss of speech or diffuse distress. School-age children may become phobic or hypochondriacal, withdrawn, or excessively care-giving. Displays of aggression may be observed in place of sadness, especially in boys who have difficulty in expressing longing. Adolescents may respond more like adults, but they may also be reluctant about expressing their emotions because of fear that they will appear different or abnormal.

Intermediate Effects

Medical Consequences. A few investigators have suggested a link between loss experiences and subsequent precipitation or "activation" of specific diseases, such as thyrotoxicosis, rheumatoid arthritis, and diabetes. ,, The literature on the medical consequences of bereavement in children is extremely limited, however.

Psychiatric Consequences. A number of psychological symptoms, most prominently neurosis and depression, appear to correlate with parental or sibling death. Signs of continuing emotional distress have been noted in both community and patient samples of children who lost a parent or sibling.

Kaffman and Elizur , found that about 40% of normal preadolescent Israeli kibbutz children who lost a father during the Yom Kippur War of 1973 continued to show severe maladaptive behavior more than three years following the death. Behavioral problems, amounting to an average of nine handicapping problems per child (e.g., soiling, social isolation, learning problems), peaked in the second year after the father's death; these represented a significant increase over prebereavement behavior. Three and a half years after the loss, 65 percent of the total clinical symptoms persisted at a medium to severe level. Assessing the chil dren at 6, 18, and 42 months postbereavement, the authors found that nearly 70 percent of the children showed signs of severe emotional disturbance in at least one follow-up period. Fewer than one-third had achieved satisfactory family, school, and social adjustment throughout the entire three and a half years of the study. A subsequent study of this sample suggested that children with preexisting emotional difficulties and those who came from families marked by marital discord were at greater risk for more severe pathologic developments than were children from stable families with no prior emotional problems.

An unevenness in the development of bereavement reactions among these Israeli children was noted. Although those with symptoms of marked emotional impairment during the early months of bereavement appeared to develop the most severe and prolonged type of pathologic grieving, others revealed no special pathology during the early months but deteriorated emotionally during the second to fourth years. Thus, the timing of severe and persistent clinical symptoms that significantly impaired the child's psychosocial functioning varied in onset and duration.

In a study comparing bereaved kibbutz and urban children, Kaffman and Elizur found that 48 percent of the kibbutz children and 52 percent of those in cities showed persistent symptoms of "pathological grief" (which the authors define as "the presence of multiple and persistent clinical symptomatology of sufficient severity to handicap the child in his everyday life within the family, school, and children's group, persisting for a minimum of two months") and displayed signs of marked distress, emotional insecurity, and psychological imbalance 18 months after notification of their fathers' deaths.

That normal kibbutz children did not fare a great deal better than city children suggests that the social supports available in the kibbutz setting and the perceived less central role of the parents did not protect the youngsters from stress. Thus, while the father within a kibbutz is neither the family provider nor principal supplier of material needs, he is still a central attachment figure in his child's emotional life. These findings highlight the importance of the psychological meaning of parental loss and its impact on a child.

In a sample of disturbed 2½- to 14-year-olds who had lost a sibling, guilt reactions, accompanied by trembling, crying, or sadness, were present in half the subjects and evident for five or more years after the death. Forty percent had prolonged or anniversary hysterical identification with the dead sibling's prominent symptoms.

Behavioral Consequences. There is general agreement among clinicians that parental bereavement has an adverse impact on school functioning, both in academic performance and social behavior. Several studies of Australian, Israeli, and American children 13 months to 6 years postbereavement showed evidence of examination failure, school refusal, a decreased interest in school activities, and drop-out. ,,, These findings parallel the general finding that school performance is very often a significant indicator of emotional difficulty.

Delinquency has been found to correlate with parental bereavement, particularly in adolescents. ,, In a controlled follow-up study of a sample of 264 Minnesota school children who had lost a parent, Gregory found that bereaved adolescents who lived with an opposite-sex parent had higher rates of delinquency than controls.

Raphael notes that loss generates longing for comforting and reassurance in girls, leading to sexualized relationships that provide a sense of ego fusion with another, whereas boys are more likely to engage in petty theft, car-stealing, fights, drug-taking, or testing of authority systems.

Long-Term (Delayed) Effects

A number of researchers have conducted retrospective studies to investigate a hypothesized link between childhood bereavement and vulnerability during adulthood to a variety of serious disorders, including neurosis, psychosis, physical illness, depression, schizophrenia, and antisocial behavior. Specific findings from these studies are contradictory, but they generally point to an increased vulnerability to physical and mental illness later in life. Findings from the one prospective study conducted by Fulton and his colleagues , also suggest that bereaved children suffer long-term vulnerabilities.

Medical Consequences. Raphael points to a number of retrospective studies suggesting that persons who have experienced such loss are more likely to demonstrate symptomatology, increased health care utilization, and complaints of ill health in adult life. She cites Seligman et al., who link early parental death with increased use of medical service by adolescents, and Schmale and Iker, who found a possible association between childhood loss and development of cancer, although (as discussed in Chapter 2) the connection has not been clearly demonstrated.

Bendikson and Fulton's prospective study of a cohort of 264 parentally bereaved Minnesota ninth graders also suggests a possible predisposition to later illness. When these individuals were observed in their thirties they were significantly more susceptible to serious medical illnesses than the control subjects, and experienced significantly more emotional distress. Unfortunately, the exact nature of the illnesses and distress was not specified.

Psychiatric Consequences. Substantially more work has been done on the possible association between early loss and mental illness, with the majority of investigators reporting a positive relationship between childhood bereavement and adult-life mental illness. Most of these researchers used psychiatric patients as subjects, although community samples have also been studied in more recent years. The emphasis has generally been on the consequences of parental death, with some attempt to further specify risk factors in terms of the sex of the deceased parent and the age and sex of the bereaved child.

The evidence is contradictory, but many investigators find a significant increase of both neurosis and psychosis in persons who experienced early bereavement when compared with controls. Links are suggested between early loss and adult-life impairment in sexual identity, development of autonomy, and capacity for intimacy. ,, The chief disagreement is over which combination of variables puts a subject at most risk. For example, Barry and Lindemann found that girls who lose a mother between birth and age 2 are at greatest risk for neurosis whereas in Norton's sample, loss of the father before age 10 was most significant.

Individuals who lose a parent or sibling in childhood have been considered to be most at risk for subsequent depressive disorders. Based on his clinical observations, Bowlby concludes that profound early loss renders people highly vulnerable to subsequent depressive disorders, with each subsequent loss triggering an upsurge of unresolved grief initially related to the early bereavement.

Research data examining the link between early loss and adult depression are only suggestive, however. In a review of controlled studies to determine if a link existed between childhood/adolescent bereavement and adult-life depression, Lloyd found that 8 out of 11 studies ,,,,,,, reported significant increases in depressive disorders among the bereaved group; childhood loss of a parent increased the risk of depression by a factor of two or three. In addition, in seven out of eight controlled studies, ,,,,,, early loss was correlated with severity of depression. Parentally bereaved subjects were more likely to experience psychotic-rather than neurotic-level depression. ,

In one well-controlled study, Brown et al. found that the incidence of maternal death prior to age 11 was significantly more frequent for depressed women in a community sample than for matched, nondepressed controls. They also found that 66 percent of those diagnosed as psychotically depressed had a history of early loss compared with only 39 percent of the neurotic depressives. There is also some suggestion that depressions associated with early bereavement tend to be reactive rather than endogenous; studies that have included the more biologically predisposed bipolar (manic-depressive) disorders typically have not established a connection between them and early bereavement. ,,

A number of studies show a link between childhood bereavement and suicide attempts in adult life (e.g., Birtchnell, Dorpat et al., Farberow and Simon, Greer, Hill, Levi et al. ). Birtchnell found that twice as many depressed suicide attempters were parentally bereaved compared with nonsuicidal depressives (66.7 percent versus 33.3 percent).

Evidence regarding bereavement as an etiologic factor in the development of schizophrenia is less convincing than that on depression. Dennehy, Hilgard, and Rosenzweig and Bray report positive findings, while Granville-Grossman and Gregory find no significant correlation.

Behavioral Consequences. Research findings are suggestive of a link between childhood loss and subsequent criminality. In Markesun and Fulton's prospective community study, men who had been bereaved in childhood had more offenses against the law when in their twenties than did controls. In samples of both male and female prisoners , the histories revealed an excess of parental death; the ''affectionless criminal" appears to be most strongly represented.

Based on clinical observations of psychotherapy patients of the BarrHarris Center for the Study of Separation and Loss During Childhood, in Chicago, Altschul and Beiser have noted difficulties in parenting when the bereaved child grows up and has children of his or her own. These difficulties seem to occur more often if the loss happened when the child was between 7 and 12, and if the deceased parent was of the same sex. They hypothesize that these problems have their roots in identifications with the dead parent and in the "lack of experience with the dead parent in developmental stages that go beyond the point of loss." Because the adults who experienced childhood bereavement at times do not expect to live longer than their parents did, some avoid emotional intimacy with their children as if to prevent too much grief and suffering if they die.

Conclusions About Outcomes

It is difficult to draw conclusions about the long-term consequences of bereavement during childhood or adolescence. The data suggest potential difficulties, but there is a lack of specificity regarding what places a bereaved youth at risk.

Concerning intermediate-term consequences, the existing literature suggests that early bereavement greatly increases a child's susceptibility to depression, school dysfunction, and delinquency. Given the immaturity of the child's personality, it seems likely that even a minor depression of 13 months' duration might inhibit or interfere with normal ego development, thereby disrupting or distorting psychological growth.

THE GRIEVING PROCESS IN CHILDREN

As discussed earlier in this chapter, the nature of children's reactions to loss will depend largely on their stage of emotional and cognitive development. Although specific manifestations of distress and the dura tion of responses vary by age and by individual, children (like adults) have been observed to go through a relatively predictable series of phases of bereavement responses.

Based on his observations of young children in a residential nursery who were separated from maternal figures, Bowlby ⁻ identified three sequential phases in response to separation and loss. When a healthy child over the age of six months was taken from his mother, a period of "protest" ensued, characterized by loud, angry, tearful behavior suggesting an expectation of and demand for reunion. This stage might last for as long as a week or more. When attempts at reunion failed to produce the desired results, a phase of "despair" set in, marked by acute pain, misery, and a sense of diminishing hope. Following this came the final stage of "detachment," during which children behaved as if they no longer cared whether or not their mothers returned; upon actual reunion, their initial reaction might be to continue avoidance behavior and withdrawal.

Elizur and Kaffman's work with kibbutz children described the course of grieving during the first four years following paternal bereavement. The immediate reaction was one of pain and grief. During the first year, the children began to examine the meanings and implications of the loss and to ask realistic questions to gain understanding of "dead" and "alive." During the second year, children were generally more understanding and accepting of the loss and defensive maneuvers decreased, but they showed a significant increase in anxiety. In order to cope, they became more dependent on their mothers and were more demanding; aggressive behavior, discipline problems, and restlessness intensified. During the third and fourth years, manifestations of overdependence still characterized two-thirds of the sample, but anxiety level and augmented aggressiveness were reduced. Despite a general trend toward greater adjustment, however, 39 percent of the previously normal sample continued to show signs of emotional distress four years after their fathers had died.

Shifts in Self-Concepts Following Bereavement

A major area of concern regarding psychological functioning following bereavement relates to negative shifts in self-concepts and selfesteem. Rochlin ⁻ and Kliman have observed that children often assess themselves more negatively after a parent's death than before. Children who interpret a parent's death as desertion because the parent did not love them may believe that they are unlovable, which may result in a persistent sense of low self-esteem.

Alternatively, a bereaved child may regard himself as hostile and destructive. The tendency of children to think in egocentric, magical ways and to equate thought with deed may lead to the belief that their destructive impulses or angry feelings destroyed the parent or sibling. This can lead to a hostile image of the self, especially if there was a great deal of competition and hostility in the prior relationship, as is likely to be true of siblings. Relatively universal death wishes can return to haunt the bereaved child in the form of feelings of responsibility and guilt. , Such feelings are more likely to be a problem if the death wishes were especially intense.

The Role of Identification in Grieving

Identification with a deceased person has been described as more common and dramatic in children than in adults. This process may represent both an unconscious defense mechanism and a conscious attempt to emulate the good qualities of the deceased. If done in moderation, such identifications can be enriching for a child. , Taken to an extreme, however, identification with a dead parent can become very frightening, as it can imply adoption of the parent's symptoms and death. Because of this fear, Wolfenstein believes that genuinely adaptive identifications in children are rare.

Johnson and Rosenblatt have noted that a socially inappropriate identification with a deceased parent may be an expression of incomplete or pathologic grief. If a child identifies too closely with adults, peers may be rejecting or critical, with a resulting loss of social supports. In addition, when such replacement roles are fostered by adults they can be felt as rather frightening pressure by the child. For example, if a new widow tells her young son that he is now "the man of the house," he may feel some literal responsibility and become anxious at the prospect of having to assume all the roles of the deceased parent (e.g., surrogate marriage partner or emotional confidant to a depressed adult). If his mother later remarries, the stress on the little "man of the house" is magnified by the fact that she has chosen to "replace" him.

Likewise, a child may attempt to replace a deceased sibling as a means to help the parent(s) cope with loss feelings, thereby compromising the youngster's own identity development. Too often the tendency to idealize the dead also makes it difficult for surviving siblings to deal with their anger at the deceased or at their parents (e.g., for not preventing the death or for seeming to care more about the deceased child). This too may form a basis for overidentification, if the child attempts to secure affection by adopting the traits of the deceased.

Common Thoughts, Concerns, and Fantasies

As with adults, a number of common themes emerge in bereaved children, typically associated with or underlying feelings of sadness, rage, fear, shame, and guilt.

There are at least three questions, whether directly articulated or not, that will occur to most children following a loss: Did I cause this to happen? Will it happen to me? Who will take care of me now (or if something happens to my surviving caretaker)? It is important to provide answers to these questions and to hear how the child understands those answers, because misunderstandings may give rise to feelings of anger or fear.

Perceptions that the parent or sibling's death was a deliberate abandonment, associated with feelings of rage, tend to undermine a child's badly needed sense of being cared for. This was indeed the reaction of 20 percent of the parentally bereaved patients studied by Arthur and Kemme.

Worries that a dead parent might return and seek revenge, concerns that what happened to the deceased parent or sibling could also happen to them or to surviving family members or caretakers, and worries that their basic physical needs for survival may not be satisfied , have all been observed. Bowlby notes that fears about whom death may claim next may underlie anxious clinging or obstinate behavior. The belief that the world is a safe, predictable place may be destroyed, resulting in disruption of a child's capacity for basic trust.

Common Defensive Strategies

Many of the reactions in bereaved children that have been described- denial, idealization of the dead parent, inhibition or isolation of griefrelated affects, identification with the lost parent, displacement-are common defensive strategies.

Psychoanalytic writers (e.g., Altschul, Deutsch, Jacobsen, and Shambaugh, ), basing their judgments on small numbers of patients, and researchers studying a sample of normal children have commented on the frequent use of denial, which they believe underlies persistent fantasies of reunion with the deceased. Elizur and Kaffman found that bereaved children fantasized in an attempt to maintain the illusion that the deceased parent was still nearby. Denial may help ward off painful feelings and a conscious consideration of the loss. Altschul, observing that such denial may continue indefinitely, feels that it is the emotional significance of the deceased person that is denied more than the reality of the death. Wolfenstein has commented on a defensive (and often maladaptive) splitting of the ego in bereaved children that allows them to acknowledge a parent's death as a reality while simultaneously denying its finality. She suggests that the good moods that may be observed in bereaved children following parental death represent an affective counterpart of denial. When depressed moods occur, particularly in adolescents, they are usually isolated from thoughts of the dead parent.

Conclusions About the Grieving Process

Although many of the reactions children display in response to a loss are similar to those observed in adults, the time frame and overt process of grieving in young people are clearly different. Because of developmental differences in their cognitive abilities and personality structures, children are likely to use more primitive defense mechanisms than adults (e.g., denial and regression) in coping with their losses. These differences put children at substantial psychological risk after the death of a family member. Denial that a death has occurred, for example, may prevent a child from confronting and working through his or her feelings of loss. Troublesome behaviors and emotions related to the bereavement may emerge months, or even years, later as a child reworks his grief.

VARIABLES AFFECTING PROCESSES AND OUTCOMES

In addition to psychological defenses, a number of other variables have been identified that affect the grieving process in children. These include age and emotional stability of the child, sex of the deceased and of the bereaved, the nature of the relationship between the child and the deceased, and the nature of social supports following bereavement.

Child's Age, Developmental Stage, and Emotional Stability at the Time of Bereavement

A number of clinicians and clinical researchers (e.g., Alexander and Adlerstein, Bowlby, Elizur and Kaffman, McConville et al., Rutter, Van Eerdewegh et al. ) report that the impact of relationship loss will be greater when it occurs at certain ages or stages than at others. Both Rutter and Bowlby have found that bereaved children under the age of five are more susceptible than older children to pathologic outcomes. But whereas Bowlby found that children aged six months to four years were at particular risk, Rutter concludes that the third and fourth years of life constitute a vulnerable period because he found an excess of parental deaths among psychiatric clinic patients during those years. He speculates that children under the age of one or two are less distressed than bereaved older children because there has been less time to develop ties.

Early adolescence also appears to be a vulnerable time in terms of significant relationship loss. Rutter , Van Eerdewegh et al., and Wolfenstein found that the severely depressed children in their studies mostly seemed to be adolescent boys who had lost their fathers. In contrast, Hilgard et al., using retrospective data, noted a number of outstandingly good adjustments among adults whose parental loss came between the ages of 10 and 15, preceded by a satisfactory home life.

Elizur and Kaffman's data ,, also suggest that although normal children are at risk following bereavement, preexisting emotional difficulties, in combination with other antecedent variables, may exacer bate symptoms during the early months following loss. Clarification is needed on the kinds of emotional disturbances and troubled family relationships that place children at greater risk.

Quality of Preexisting Relationship with the Deceased

Sex of Deceased Parent and Bereaved Child

Studies of the impact of and interaction between the sex of the deceased parent and that of the child have produced interesting but somewhat contradictory results. Kliman , has observed that from about age three onward, while yearning for the dead parent tends to be more overt when the opposite-sex parent dies, special anxieties may develop when the same-sex parent dies, especially if the child begins to fear that he or she must in some way become the "new daddy" or "new mommy" of the family. In clinical samples, Fast and Cain found that boys who lost fathers felt threatened by and therefore tried to avoid positive feelings toward their mothers, while Arthur and Kemme found that girls showed a greater tendency to idealize dead fathers.

Retrospective studies of the association between early parental loss and adult-life depression in community samples and studies of women psychiatric patients ,, suggest that girls are more vulnerable than boys to parental bereavement in general and more vulnerable to loss of a father during adolescence. ,,

Quality of the Child's Support System

As discussed throughout this report, social support is a modifying variable that can soften trauma. Unfortunately, children's primary source of support is usually the surviving parent, who also has been traumatically affected by the death of a spouse or child.

Widows, usually sad and anxious following conjugal bereavement, often express impatience and irritation with children who simultaneously have special needs. , After a parent dies, modes of discipline often change, with the surviving parent either becoming excessively strict or lax or being inconsistent. Rutter found that bereaved children frequently experienced multiple life-style changes in the context of makeshift arrangements following the death, with a few being placed in institutions. Rather than the atmosphere of stability and consistency necessary for a better outcome, the common situation following a parental death may be considerable chaos, disorganization, and a sense of insecurity.

Other protective factors include the presence of a mother who can use a network of support outside the home, prebereavement years spent in a home with two compatible parents who had well-defined roles so that early identifications were good, and parental attitudes that fostered independence and a tolerance for separation. , Hilgard et al. note that "appropriate" grieving by the surviving parent and avoidance of excessive dependency on the children had helped their well-adjusted sample work through the loss and achieve a satisfactory adaptation following parental death.

In addition to the role of the surviving parent following a death in the immediate family, it would seem that grandparents, aunts and uncles, and perhaps close family friends, could step in to assist the bereaved child. The impact of nonparent figures on the course of children's bereavement reactions has not been documented.

Remarriage of the Surviving Parent

In a controlled retrospective study of women in a community whose mothers died before they reached age 11, Birtchnell found that only those who experienced poor relationships with mother replacements emerged with major psychological problems. These women tended to manifest neurotic depressions of moderate intensity and were more prone to severe and chronic anxiety symptoms than bereaved women not characterized by such relationships.

Cultural Background

Although it has been suggested that cultural factors, such as ethnic background, social class, and religion, play a role in determining the child's understanding of and response to loss, this is an area in which very little research has been done. Based on child interview data, Tallmer et al. have concluded that children from lower socioeconomic class families are more aware of at least the concept of death, due to the increased amount of violence and death in their social environ ments. In their studies comparing bereaved kibbutz and urban children in Israel, Kaffman and Elizur , found that differences in child-rearing methods, family functioning style, and social setting influenced the type of problems that became prominent following paternal death.

Circumstances of the Death

The type of death experienced-e.g., anticipated versus unanticipated, in the home versus in the hospital-influences the child's bereavement response. Erna Furman comments that there are no peaceful deaths for parents of young children, and each type of death is associated with particular anxieties; the kinds and sources of anxiety vary with the child and his situation.

It is generally agreed that an anticipated death is easier for children to cope with than sudden loss-just as it is for adults-because forewarning seems to provide an opportunity to prepare at least cognitively. If a parent is ill for a prolonged period of time, however, the child often has to deal with knowledge of a series of surgical and medical interventions that may be interpreted as bodily assaults. If the particular form of a parent's or sibling's terminal illness or injury coincides with and gives reality to developmentally appropriate but otherwise transient concerns, the already existing worries may be intensified and rigidified.

Suicide. As discussed in Chapter 4, suicide is generally considered the most difficult type of death to accept. For children, the suicide of a parent or sibling not only presents immediate difficulties, but is thought by many observers to result in life-long vulnerability to mental health problems.

Pynoos and his colleagues , have reported on children's immediate reactions to witnessing suicide attempts and homicides. Regardless of what has been told to children, it is clear that they know fundamentally what has transpired and that they promptly institute defensive adaptive measures, including denial in fantasy and reworking of the facts in accord with stage-related concerns.

In a partially controlled study, Shepherd and Barraclough followed 36 children (ages 2-17 years) five to seven years after the suicide of a parent and found greater psychiatric morbidity among the suicide survivors than among a comparison group. They also noted that prebereavement home life was abnormal for these subjects because of the stresses of living with a parent who was mentally ill. In fact, for a few of the children, the suicide was experienced as a relief from a previously "insupportable situation."

In their assessment of 45 disturbed children four years after the suicide of one parent, Cain and Fast found a broad range of psychological symptoms, including psychosomatic disorders, obesity, running away, delinquency, fetishism, lack of bowel control, character problems, and neurosis. Compared with other childhood bereavement cases, there was a much higher incidence of psychosis (24 percent versus 9 percent). Common disturbed reactions among this group included a very intense sense of guilt and distortions of communication. As they often receive the message that they should not know or tell about the suicide, these children frequently are in conflict about learning and knowing in general, with resultant learning disabilities, speech inhibitions, and reality sense disturbances.

Parental suicide also appears to be linked with serious long-term negative consequences. For example, Dorpat, examining the case material of 17 adult psychiatric patients who were seen an average of 16 years after the parent's death, found guilt over the suicide, depression, morbid preoccupation with suicide, self-destructive behavior, absence of grief, and arrests of certain aspects of ego, superego, and libidinal development.

Summary of Risk Factors in Childhood Bereavement

A review of the clinical and research data suggests that the following factors increase the risk of psychological morbidity following the death of a parent or sibling during childhood years:

loss occurs at an age below 5 years or during early adolescence,

loss of mother for girls below age 11 and loss of father for adolescent boys,

psychological difficulties in the child preceding the death (the more severe the preexisting pathology, the greater the postbereavement risk),

conflictual relationship with the deceased preceding the death,

psychologically vulnerable surviving parent who is excessively dependent on the child,

lack of adequate family or community supports or parent who cannot make use of available support system,

unstable, inconsistent environment, including multiple shifts in caretakers and disruption of familiar routines (transfer to an institutional setting would be an extreme example),

experience of parental remarriage if there is a negative relationship between the child and the parent replacement figure,

lack of prior knowledge about death,

experience of parent or sibling suicide or homicide.

INTERVENTION STRATEGIES

Adults often become uneasy when called upon to deal with children on topics of conception, birth, or death. Clinical and research findings suggest that parents often fail to inform their children when a loved one dies, or they do so in an inappropriate or upsetting way, thereby increasing the likelihood of further distressing youngsters who are incapable of seeking out the truth for themselves. Although there are no systematic studies assessing the safety and efficacy of different intervention strategies, psychological theory and clinical experience do suggest an approach.

Anticipating Parental Death

There is some research evidence that short-term professional ''preventive therapy" with children of fatally ill parents may also decrease the likelihood of subsequent pathology after a parent dies. In a controlled study of normal, randomly assigned children, ages 10-14, Rosenheim and Ichilov found that brief treatment (10 to 12 weekly home visits) made a significant difference in terms of the anxiety level and social and scholastic adjustment of children who were anticipating parental death. Sessions focused on the child's perception of the parent's illness and his or her reactions to it, the factual life situation at home (present, past, and anticipated future), the child's feelings toward his parents, and his or her self-concept. An opportunity was provided for catharsis while therapists helped supply realistic perspectives about in ner and outer realities (e.g., the resources available to the child in the face of loss).

Helping Parents to Help Their Children

The most important preventive intervention may be how parents and others deal with children who have been bereaved. In the interests of helping parents to provide their children with a supportive, understanding environment, this section offers some specific suggestions based on information in the literature and on the best judgment of the committee.

Providing optimal support to grieving children may be difficult, not only because the parents themselves are extremely upset, but also because they may be uncertain of what to expect from a child. Thus, it is important that parents learn about the grieving process in children so they will know what to expect and will not become alarmed about the differences between childhood and adult grieving. Knowing that the child may ask distressing questions, such as when will there be a new parent or sibling to replace the one who was lost, may eliminate surprise and hurt. Such questions do not indicate a shallow attachment to the deceased, but rather the manner in which young children typically respond to loss.

Children may confront strangers with news of the death to test reactions and gauge their own responses. They may play "funeral or "undertaker" games for a few days following the death of a family member in order to master the situation. Children may manifest a superficially milder reaction to the loss because of the strong defenses that protect them from becoming flooded with overwhelming emotions. As noted earlier, troubling emotions or behaviors emerging months or years after the death may be related to the bereavement, because children give up their attachment to the deceased much more slowly than adults usually do. Preparing for and understanding such behaviors and coping responses can help avoid or modify reactions of shocked hurt or anger in parents that could intensify the child's feelings of confusion and guilt.

Providing concrete recollections of the deceased parent or sibling may also be helpful. Photographs and clothing or other possessions of the deceased are meaningful to a child because they represent the deceased person as well as the child's own past relationship with that person.

Talking to Children About a Family Member's Death

Most authors agree that there is preventive value in educating children about death when they are young, long before death is likely to enter their lives in an emotionally threatening way. As Reed points out, children begin asking questions about death at an early age. They are naturally curious about such phenomena and provide adults with opportunities to intervene.

Various educational tools have been suggested. Chaloner, Ema Furman, and Koocher recommend using the death of a child's pet or other naturally occurring teaching moment to introduce the concept. Opportunities such as driving past a cemetery or coming across a dead animal while on a nature walk can also be used to provide awareness and understanding, especially that the deceased animal or person will never return. Moreover, it will provide the child with the reassurance that death is not a topic to be avoided with adults. Other means to help children gain awareness about death include children's books (see Goldreich for a list) and formal death education classes.

When informing a child of a family member's death, a number of variables may be important, including who tells the child, the timing of the information, and the manner in which the child is informed.

In most cases, a family's existing belief system will determine what they do. However, families sometimes contact health care professionals to ask for advice. Professionals need to be cautious in making recommendations under these circumstances. Since there is wide cultural and family variation, it is important for the health care provider to draw upon his or her knowledge of that family and their culture, taking into consideration the family's own wishes and inclinations. The child's level of social, emotional, and cognitive development, the meaning of the event to the child and family, and the child's fantasies about the death should all be kept in mind when determining what is appropriate for a particular child to be told. When possible, decisions should be made within the context of a dialogue with the family.

Use of religious explanations, in particular, is controversial. Some Western observers think that explanations about the deceased going to heaven may be upsetting to children who think and interpret things more concretely than adults. ,, Others, however, have remarked on the comfort that religious beliefs can provide following bereavement. What is most suitable for a particular child will depend on the factors cited above; what is probably most important is that explanations remain consistent with the family's values and beliefs.

In the case of sudden death, the surviving parent can acknowledge a child's observations and clarify misperceptions or misinterpretations. Specific facts may be added as the child is able to integrate them. As is true for adults, it is generally agreed that knowledge helps provide a sense of security. In disturbing situations or crises, feelings of helplessness increase with ignorance of the facts.

It is relieving for bereaved children to be told that they will not succumb to the same fate as the deceased, and that they will continue to be cared for. Particularly when dealing with young children, it can be important to reassure a child that the family will remain together and that he or she will be told step by step as each arrangement is planned. It is also helpful for young children to gain an understanding of the difference between the self and the deceased. Telling them that neither they nor other surviving family members will die just because of the other death can help the children differentiate reality from fantasy.

It may be helpful to ask children for a replay of what they have understood by saying something like, "Now pretend that one of your friends asks you about this. What would you answer?" By asking specific questions and letting the child reply, the adult can detect and correct misconceptions quickly.

It may be useful for parents to become aware of potential pitfalls that can emerge following bereavement. For example, parents' capacities to nurture their children may diminish after the death of a family member due to their own grief and loneliness. Because of their own needs during this time, parents may be inclined to turn to their children for emotional support. It may feel gratifying to a child to be able to help a dis traught parent, but this responsibility may also be experienced as frightening and overwhelming. Feeling excessive responsibility for a parent can also impede subsequent establishment of autonomy and intimacy with others.

Missing the deceased spouse or child, a parent may look for or notice similarities between the deceased and a surviving child, and even comment on these similarities, implicitly suggesting that the child should function as a replacement for the person who died. The child's sense of personal worth and value may be compromised by this view of being a replacement for someone else, and such perceptions may result in unrealistic life plans.

Attending the Funeral

Parents frequently express uncertainty about whether children should attend funeral services, fearing that such participation might frighten or otherwise upset them. Most authors who deal with this subject recommend that children be allowed, but not forced, to participate in family mourning and funeral rites if they wish to do so. As with adults, participating in mourning rituals helps children to mark the death and cope with their feelings. Such participation may help children understand the finality of death and aid in dispelling fantasies.

The parent can help prepare the child for the funeral service by explaining in advance how the room will look, where they will be sitting, and what they can expect to see and hear. Arranging to have a relative or close family friend sit with the child and be available to leave with him should the child wish to may be helpful.

It should be noted, however, that there is great diversity in funerals across cultures and some services might be more difficult for a child to handle than others. Erna Furman has observed that even a young child can take in stride some aspects that might otherwise be upsetting as long as the parent(s) feel comfortable with the funeral service. She adds, however, that parents can modify customs to ease the experience for the child. For example, arrangements could be made to shorten the service or to have a closed casket. Children should be told in advance if the casket is to remain open, and may be given the opportunity to look at or touch the deceased one last time if they want. Observers agree that it is unwise to insist, however, that a child touch a corpse.

In general, by anticipating and addressing all the things a child might see, hear, or have concerns about regarding the funeral procedures, adults may be better prepared to discuss the event in an emotionally supportive manner. A cemetery, for example, may be explained as a pretty and quiet place where people can go whenever they want to be near the dead person's body and remember that individual.

Anniversary Reactions: A Normal Long-Term Consequence

As discussed in the preceding chapters on adults, not all long-term consequences of bereavement are pathologic. For example, in a pilot study of bereaved former psychiatric patients, Plotkin found that reactions to birthdays, holidays, and anniversaries of the death were a normal and predictable part of the grieving process. She argues that such late-occurring manifestations of grief should not be confused with pathologic grief, and she advocates using such reactions as healthy opportunities to express feelings about the death.

Johnson and Rosenblatt also distinguish between late-occurring " incomplete" or "pathological" grief and the grief that reemerges in children as a result of maturation and new experience. Sometimes anniversaries or life marker events provide occasions for the emergence of psychopathologic symptoms for the first time in previously well-adjusted youngsters; but more commonly, quite normal manifestations of grief will recur with such developmentally significant events as communion, graduation, pregnancy, or the return to a place an individual previously visited with the deceased parent or sibling. Such feelings may be associated with a conscious realization that the deceased is not present to share the event or they may take place without any understanding of why the distress has surfaced at that time. The most helpful intervention for this type of grief is supportive assurance that sadness under these circumstances is normal and common among those who have lost a significant person.

When to Seek Professional Help

As with adults, the distinction between normal and pathologic grieving in children is not always clear. Following a loss as profound as the death of a parent or sibling, some behaviors and reactions are to be expected that otherwise might be considered pathologic. In normal childhood grieving, it is not unusual to see clinical symptoms of emotional disturbance, some regression, denial, and an inability to function. Children may not report much distress, but their behavior may seem immature for their age.

In discussions at one of the committee's site visits, Kliman added to this list the inability or unwillingness to speak of the deceased parent, exaggerated clinging to the surviving parent, and expression of only positive or only negative feelings about the deceased. A manifest absence of grief, strong resistance to forming new attachments, complete absorption in daydreaming resulting in a prolonged dysfunction in school, or new stealing or other illegal acts may also be a cry for help.

Some clinicians (e.g., Kliman) who take the position that all children who lose a parent through death are "at risk" recommend at least some time-limited intervention in all cases, whether or not a child displays the behaviors cited. From this perspective, each child who loses a significant family member would be assessed periodically as a preventive measure.

It is important for parents to be aware of danger signals so that they can know if and when professional help should be sought. Educating parents about normal versus pathologic responses can help them make such decisions.

Conclusions About Interventions

Although there is little scientific evidence regarding the effect of intervention either prior or subsequent to bereavement during childhood, there is general agreement that promptness, honesty, and supportiveness help. Information should be geared to the child's emotional and intellectual level and ample opportunities provided for the child to ask questions about the death. Children need rituals in order to memorialize loved ones just as adults do, and should be allowed to participate in funeral or memorial services to the degree to which they feel comfortable.

Although both short- and long-term distress should be expected and are normal, some professional mental health intervention conceivably may be useful for all bereaved children, or at least when particular patterns of troublesome response become evident.

RECOMMENDATIONS FOR FUTURE RESEARCH

In order to achieve better understanding of the nature of the bereavement process and its potential impact, there is a need for methodologically sound studies in which representative samples of bereaved children are followed for several years and are compared with nonbereaved children. Following are some of the important questions that should be addressed:

What are the signs and symptoms of pathologic versus normal grief following parental or sibling death?

What conditions foster or inhibit adaptation?

What are the preexisting or concurrent risk factors associated with poor outcomes, including major psychiatric disorder?

How do identified risk factors hold up over the course of the first several years following bereavement?

What is the relationship between the sex of the deceased parent and the age and sex of surviving children on the course of bereavement reactions?

How do children who are in various stages of normal cognitive and personality development at the time of bereavement do in comparison with each other and how do they compare with nonbereaved children of the same developmental stage?

How does early loss exert a detrimental impact on children?

How do the effects of bereavement and the process of grieving differ for surviving parents and children?

Particular attention should be paid to the design of studies seeking to address questions such as these so that methodological shortcomings do not compromise the conclusions. Grieving children who are not in psychotherapy should be directly observed and assessed. Too much emphasis in the existing literature has been placed on retrospective analysis, memories and extrapolations from adulthood, on parental reports of children's reactions, and on observations of children in treatment who may or may not be representative of grieving children generally. Although clinical case studies will continue to provide useful, in-depth information, prospective, clinically sensitive, longitudinal studies of community samples are also needed in order to further current understanding and resolve controversy about the nature of grieving and the impact of loss on children.

Another series of potentially very important studies would involve the random assignment of bereaved children to a variety of different treatment or control groups to determine whether treatment facilitates adaptation to the extent that certain treatment approaches are indeed successful; other studies should identify the essential process or mechanisms by which children are helped. Identification of the most effective methods of preventive intervention for particular children or groups of children, and at what stage of life and what distance from the loss these interventions should take place, would add significantly to current knowledge.

In sum, it is time to move to modern standards of research in the area of childhood bereavement. Young people who have lost a parent or sibling through death need to be tracked to determine both short- and long-term consequences of bereavement and to identify subgroups most at risk for pathologic developments. Methods of intervention must be subjected to tests of efficacy to determine how best to help children, with new or modified techniques being particularly designed for the pathologically grieving child.

REFERENCES

This chapter was prepared by Janice L. Krupnick, M.S.W., consultant, supported in part by the Kenworthy-Swift Foundation, New York. Background materials and assistance were provided by committee members Gerald Koocher, Ph.D., and Theodore Shapiro, M.D., and by Fredric Solomon, M.D.

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Bereavement During Childhood and Adolescence

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It is not clear exactly how many young people are affected by the death of an immediate family member. Kliman 82 estimates that 5 percent of children in the United States-1.5 million-lose one or both parents by age 15; others suggest that the proportion is substantially higher in lower socioeconomic groups.