Depression
in Recently Ronald
Mary
Objective: The reaved prepubertal
Bereaved
A. Weller,
A. Fristad,
purpose children
M.D.,
Elizabeth
Ph.D.,
of this study and compare
Prepubertal B. Weller,
and Jennifer
was to ascertain these symptoms
Children
M.D.,
M. Bowes,
B.A.
depressive symptoms with those ofdepressed
children. Method: The subjects were 38 children who had recently one but not both of their parents. They had to meet strict inclusion of bereavement per se, rather than other significant stressors, could
in recently beprepubertal
experienced the death of criteria so that the effects be assessed. The compari-
son group consisted of 38 hospitalized, depressed children individually matched reaved subject for age, sex, and socioeconomic status. All ofthe children underwent and comprehensive evaluation. They and their parents were independently
to each besystematic evaluated by
trained interviewers dren and Adolescents.
using the parent and child versions of the Diagnostic Interview Family histories and basic demographic information were
tamed.
recently
Results:
The
bereaved
children
endorsed
many
depressive
for Chilalso ob-
symptoms.
Thirty-
seven percent of them met the DSM-III-R criteria for a major depressive episode. The depressed children, however, had more depressive symptoms on average than the bereaved children. The factors associated with increased depressive symptoms in the bereaved children were 1) the mother as the surviving parent, 2) preexisting untreated psychiatric disorder in the child, 3) family history siderable number ofthe sive
episode
and children
after
death
immediately
subsequent studied (Am
ofdepression, bereaved
course
the
ofgriefand
further. J Psychiatry
1991;
to major
4) high developed
of a parent. depressive
percent (approximately 1 .2 million) of children in the United States experience the death of a parent before the age of 15 (1 ). However, there has been little systematic research on children’s reactions to parental death and the relation of bereavement occurring in childhood to subsequent psychopathology (2). In particular, information regarding symptoms of depression experienced by bereaved children is not available. Without such information, accurate differentiation between normal grief and depression in children may not be possible. In adults, grief has been empirically differentiated from depression. Factors reported to differentiate the two indude feelings of worthlessness, marked psychomotor me-
Received Dec. 20, 1989; revision received April 8, 1991; accepted May 20, 1991. From the Department of Psychiatry and the NeuroProgram,
to Dr. Ronald University,
Rm.
43210. Supported mation
Center
The
Ohio
A. Weller, 61,
in part and
State
Upham
Hall,
by grants the
Ohio
Bremer grant and a seed grant Copyright © I 991 American
1536
University.
Department 473
from
Address
of Psychiatry, West
12th
the National
Department
The disorder
status. symptoms
relation remains
Conclusions: ofa major
of these unknown
A condepres-
symptoms and
to the should
be
148:1536-1540)
pour
science
socioeconomic the clinical
of
Ave.,
reprint Columbus,
Research Mental
requests
The Ohio
State OH
and Infor-
Health
from The Ohio State University. Psychiatric Association.
and
a
tardation, and functional impairment (DSM-III-R). When present, these factors may indicate that bereavement is complicated by a major depressive episode. Studies of adults (3, 4) have provided useful models for studying bereavement in children. However, differences in social, emotional, cognitive, and physical development preclude assuming that bereavement reactions in children are identica! to those ofadults. Consequently, bereavement should be studied directly in children. Previous studies of bereavement in childhood have been limited in several ways. In many studies, the subjects were children who were already receiving psychiatnic treatment at the time of the parent’s death (5-9). However, grief in psychiatrically ill children cannot be assumed to be similar to grief in normal children. Studies have also been limited by the use of subjective ratings rather than standardized rating scales to assess psychopathology (5, 6). Studies of normal prepubental children’s reactions to parental death have been even more limited. Elizur and Kaffman (10) examined grief reactions in children aged 2-10 years whose fathers had died. Information from semistructured interviews with the children’s mothers and teachers indicated that the children had sleep dis-
AmJ
Psychiatry
148:11,
November
1991
WELLER,
turbance, social withdrawal, and restlessness. However, the subjects in both this study and another study ( 1 1 ) with similar results were children living on a kibbutz in Israel whose fathers had died in a national war. Thus, the findings may have limited generalizability. Van Eerdewegh et a!. (12) also reported numerous depressive symptoms following the death of a parent in children aged 2-1 7 years. The depressive symptoms included dysphonia, withdrawal, sleep disturbance, and anhedonia. More psychopathology was found in the children of psychiatrically ill (usually depressed) mothems. However, this information was obtained solely from ancillary sources (i.e., data were not obtained directly from the children). Failure to interview the child may result in underreporting of subjective symptoms such as dysphonia and anxiety (13). The purpose of this study was to ascertain depressive symptoms in recently bereaved prepuberta! children, compare and contrast the depressive symptoms in these bereaved children with those found in depressed children, compare parent and child reports of depressive symptoms, and determine risk factors associated with the development of depressive symptoms in the bereaved children.
METHOD
The subjects were 38 prepubertal children who had experienced the recent death of one but not both of their parents. To eliminate stressons other than bereavement as factors that could affect symptoms, we specifically excluded children of families with financial difficulties, chronic illness and/or psychiatric illness, or recent divorce in the nuclear family. Only children from families who met the following criteria were included: 1 ) at least one parent had been employed for the majority of the time in the preceding 2 years, 2) there was no chronic incapacitating illness in either the children on the parents other than that associated with the deceased parent’s death, 3) no member of the nuclear family had had psychiatric treatment in the previous 2 years, and 4) when children of divorced parents were included, the divorce had occurred at least 2 years earlier, and the children had weekly contact with both parents. In addition, the surviving parent had to be able to be interviewed and complete the questionnaires. The children we studied met the following additional criteria: 1 ) an IQ of at least 70, 2) no chronic incapacitating medical or psychiatric illness, and 3) ability to be interviewed and complete self-report inventories with assistance. Finally, the subjects had to live within SO miles of the study center. Virtually all deaths in this area are reported in the obituaries published in local newspapers, so these were used to identify bereaved families in which there was a surviving spouse and at least one child. The funeral home director or clergyman was contacted to discuss the nature of the study and the appropriateness of contacting the family. If it was considered appropriate, the
AmJ
Psychiatry
148:11,
November
1991
WELLER,
FRISTAD,
ET AL.
family was contacted, and if the family was willing, family members were screened to determine whether they met the inclusion criteria. Of 101 potential study families with children aged 5-12 years who were within a SO-mile radius ofthe study center, 23 could not be contacted because phone numbers and addresses were unavailable. An additional 30 families did not wish to participate. Of the remaining 48 families, 26 met the inclusion criteria and consented to participate. Although we would have preferred a greater rate of participation, the rate in this study was comparable to that obtained in a previous study of bereavement which used a nonrefenred sample (14). The 38 bereaved children were aged 5-12 years (mean±SD=8.9±2.4 years), and about half (53%, N= 20) were female. The number of children interviewed per family ranged from one to three (mode=1 ). For 23 children (61%) the parent’s death was anticipated (e.g., from cancer), and for 15 (39%) the death was unanticipated (e.g., from cardiopulmonary arrest, stroke, or accident). Children whose parents’ deaths were the result of suicide and homicide were not included. The surviving parents’ ages ranged from 25 to 47 years (mean± SD=36.0±S.2 years), and most of these parents (73%, N=19) were mothers. Socioeconomic status, as assessed by the Hollingshead-Redlich index (15), ranged from upper (class I) to lower (class V), with most subjects in the middle class (class III). This bereaved sample has been previously described (16). A comparison group of 38 depressed children was recruited from the child psychiatry inpatient unit at a university teaching hospital during the same period in which the bereaved children were recruited. The depressed children were individually matched to each bereaved subject for age (mean±SD=9.1± 1.9 years), sex, and socioeconomic status. Children and parents were independently and simultaneously evaluated by clinically trained interviewers. For the bereaved group, interviews occurred 3-12 weeks after the death of the parent (mean±SD=7.9±2.S weeks). The inpatient depressed children were interviewed upon admission to the hospital. Although all interviewers were similarly trained, different interview-. ens assessed the bereaved and depressed groups. Prior to each interview, the interviewers met with the parent and child or children and explained the procedure. The interviews began after the parent gave informed consent and each child’s assent had been received. Multiple structured interviews and rating scales were used to evaluate the bereaved group. Those used for this particular study included the parent and child forms of the Diagnostic Interview for Children and Adolescents ( 1 7). These are structured interviews to establish the presence on absence of psychiatric diagnoses for the child on the basis of DSM-III criteria. For the purposes of this study, all subjects were asked all depression questions from this diagnostic interview regardless of whether they answered yes to the four cardinal questions at the beginning of the section that assesses depressive symptoms. The parents of the bereaved chil-
1537
DEPRESSION
IN
BEREAVED
CHILREN
Symptoms in 38 Bere aved and 38 Depressed Prepubertal Children as Reported by the Children and by Their Parentsa
TABLE 1 . Depressive
Parent and/or Child
Report
Parent
Depressed
Bereaved
Depressed
Children
Children
Children
Children
N
%
N
%
N
Dysphoria Lossofinterest Appetite disturbance Sleep disturbance Psychomotor agitation Fatigue
20 13 8 II 12 3
53 34 21 29 32 8
31 21 22 28 25 18
82’ 55
21
29
76d
18
Guilt/worthlessness
8
Trouble
2
thinking
Morbid/suicidal ideation Diagnosis of major depressive (DSM-III-R criteria)
episode
GAll comparisons
bereaved
are
between
Child
Bereaved
Item
or retardation
Report
S
29
76
23
26
17
37
8 2
21
66’
4
47d
1 6 3 11 3
18
47
29
47 76
10
26
28
74
S
14
8
26
68 37 68
11
13
34e
3 16 8 29
20 21 16 24
53d
42 63
8
25
66
depressed
children
N
%
61
36
95’
12
45 24 32
32 26 35
84c 68c 92c
14
37
14 S
37
29 29 32
76 76c 84c
23
13 61
25 34
66 89
14
37
36
95C
9
55d
f and
Children
%
14
74d
Depressed
Children
N
N
58b
Bereaved
%
%
Report
f
by McNemar’s
test.
b
in Recently Ronald
Mary
Objective: The reaved prepubertal
Bereaved
A. Weller,
A. Fristad,
purpose children
M.D.,
Elizabeth
Ph.D.,
of this study and compare
Prepubertal B. Weller,
and Jennifer
was to ascertain these symptoms
Children
M.D.,
M. Bowes,
B.A.
depressive symptoms with those ofdepressed
children. Method: The subjects were 38 children who had recently one but not both of their parents. They had to meet strict inclusion of bereavement per se, rather than other significant stressors, could
in recently beprepubertal
experienced the death of criteria so that the effects be assessed. The compari-
son group consisted of 38 hospitalized, depressed children individually matched reaved subject for age, sex, and socioeconomic status. All ofthe children underwent and comprehensive evaluation. They and their parents were independently
to each besystematic evaluated by
trained interviewers dren and Adolescents.
using the parent and child versions of the Diagnostic Interview Family histories and basic demographic information were
tamed.
recently
Results:
The
bereaved
children
endorsed
many
depressive
for Chilalso ob-
symptoms.
Thirty-
seven percent of them met the DSM-III-R criteria for a major depressive episode. The depressed children, however, had more depressive symptoms on average than the bereaved children. The factors associated with increased depressive symptoms in the bereaved children were 1) the mother as the surviving parent, 2) preexisting untreated psychiatric disorder in the child, 3) family history siderable number ofthe sive
episode
and children
after
death
immediately
subsequent studied (Am
ofdepression, bereaved
course
the
ofgriefand
further. J Psychiatry
1991;
to major
4) high developed
of a parent. depressive
percent (approximately 1 .2 million) of children in the United States experience the death of a parent before the age of 15 (1 ). However, there has been little systematic research on children’s reactions to parental death and the relation of bereavement occurring in childhood to subsequent psychopathology (2). In particular, information regarding symptoms of depression experienced by bereaved children is not available. Without such information, accurate differentiation between normal grief and depression in children may not be possible. In adults, grief has been empirically differentiated from depression. Factors reported to differentiate the two indude feelings of worthlessness, marked psychomotor me-
Received Dec. 20, 1989; revision received April 8, 1991; accepted May 20, 1991. From the Department of Psychiatry and the NeuroProgram,
to Dr. Ronald University,
Rm.
43210. Supported mation
Center
The
Ohio
A. Weller, 61,
in part and
State
Upham
Hall,
by grants the
Ohio
Bremer grant and a seed grant Copyright © I 991 American
1536
University.
Department 473
from
Address
of Psychiatry, West
12th
the National
Department
The disorder
status. symptoms
relation remains
Conclusions: ofa major
of these unknown
A condepres-
symptoms and
to the should
be
148:1536-1540)
pour
science
socioeconomic the clinical
of
Ave.,
reprint Columbus,
Research Mental
requests
The Ohio
State OH
and Infor-
Health
from The Ohio State University. Psychiatric Association.
and
a
tardation, and functional impairment (DSM-III-R). When present, these factors may indicate that bereavement is complicated by a major depressive episode. Studies of adults (3, 4) have provided useful models for studying bereavement in children. However, differences in social, emotional, cognitive, and physical development preclude assuming that bereavement reactions in children are identica! to those ofadults. Consequently, bereavement should be studied directly in children. Previous studies of bereavement in childhood have been limited in several ways. In many studies, the subjects were children who were already receiving psychiatnic treatment at the time of the parent’s death (5-9). However, grief in psychiatrically ill children cannot be assumed to be similar to grief in normal children. Studies have also been limited by the use of subjective ratings rather than standardized rating scales to assess psychopathology (5, 6). Studies of normal prepubental children’s reactions to parental death have been even more limited. Elizur and Kaffman (10) examined grief reactions in children aged 2-10 years whose fathers had died. Information from semistructured interviews with the children’s mothers and teachers indicated that the children had sleep dis-
AmJ
Psychiatry
148:11,
November
1991
WELLER,
turbance, social withdrawal, and restlessness. However, the subjects in both this study and another study ( 1 1 ) with similar results were children living on a kibbutz in Israel whose fathers had died in a national war. Thus, the findings may have limited generalizability. Van Eerdewegh et a!. (12) also reported numerous depressive symptoms following the death of a parent in children aged 2-1 7 years. The depressive symptoms included dysphonia, withdrawal, sleep disturbance, and anhedonia. More psychopathology was found in the children of psychiatrically ill (usually depressed) mothems. However, this information was obtained solely from ancillary sources (i.e., data were not obtained directly from the children). Failure to interview the child may result in underreporting of subjective symptoms such as dysphonia and anxiety (13). The purpose of this study was to ascertain depressive symptoms in recently bereaved prepuberta! children, compare and contrast the depressive symptoms in these bereaved children with those found in depressed children, compare parent and child reports of depressive symptoms, and determine risk factors associated with the development of depressive symptoms in the bereaved children.
METHOD
The subjects were 38 prepubertal children who had experienced the recent death of one but not both of their parents. To eliminate stressons other than bereavement as factors that could affect symptoms, we specifically excluded children of families with financial difficulties, chronic illness and/or psychiatric illness, or recent divorce in the nuclear family. Only children from families who met the following criteria were included: 1 ) at least one parent had been employed for the majority of the time in the preceding 2 years, 2) there was no chronic incapacitating illness in either the children on the parents other than that associated with the deceased parent’s death, 3) no member of the nuclear family had had psychiatric treatment in the previous 2 years, and 4) when children of divorced parents were included, the divorce had occurred at least 2 years earlier, and the children had weekly contact with both parents. In addition, the surviving parent had to be able to be interviewed and complete the questionnaires. The children we studied met the following additional criteria: 1 ) an IQ of at least 70, 2) no chronic incapacitating medical or psychiatric illness, and 3) ability to be interviewed and complete self-report inventories with assistance. Finally, the subjects had to live within SO miles of the study center. Virtually all deaths in this area are reported in the obituaries published in local newspapers, so these were used to identify bereaved families in which there was a surviving spouse and at least one child. The funeral home director or clergyman was contacted to discuss the nature of the study and the appropriateness of contacting the family. If it was considered appropriate, the
AmJ
Psychiatry
148:11,
November
1991
WELLER,
FRISTAD,
ET AL.
family was contacted, and if the family was willing, family members were screened to determine whether they met the inclusion criteria. Of 101 potential study families with children aged 5-12 years who were within a SO-mile radius ofthe study center, 23 could not be contacted because phone numbers and addresses were unavailable. An additional 30 families did not wish to participate. Of the remaining 48 families, 26 met the inclusion criteria and consented to participate. Although we would have preferred a greater rate of participation, the rate in this study was comparable to that obtained in a previous study of bereavement which used a nonrefenred sample (14). The 38 bereaved children were aged 5-12 years (mean±SD=8.9±2.4 years), and about half (53%, N= 20) were female. The number of children interviewed per family ranged from one to three (mode=1 ). For 23 children (61%) the parent’s death was anticipated (e.g., from cancer), and for 15 (39%) the death was unanticipated (e.g., from cardiopulmonary arrest, stroke, or accident). Children whose parents’ deaths were the result of suicide and homicide were not included. The surviving parents’ ages ranged from 25 to 47 years (mean± SD=36.0±S.2 years), and most of these parents (73%, N=19) were mothers. Socioeconomic status, as assessed by the Hollingshead-Redlich index (15), ranged from upper (class I) to lower (class V), with most subjects in the middle class (class III). This bereaved sample has been previously described (16). A comparison group of 38 depressed children was recruited from the child psychiatry inpatient unit at a university teaching hospital during the same period in which the bereaved children were recruited. The depressed children were individually matched to each bereaved subject for age (mean±SD=9.1± 1.9 years), sex, and socioeconomic status. Children and parents were independently and simultaneously evaluated by clinically trained interviewers. For the bereaved group, interviews occurred 3-12 weeks after the death of the parent (mean±SD=7.9±2.S weeks). The inpatient depressed children were interviewed upon admission to the hospital. Although all interviewers were similarly trained, different interview-. ens assessed the bereaved and depressed groups. Prior to each interview, the interviewers met with the parent and child or children and explained the procedure. The interviews began after the parent gave informed consent and each child’s assent had been received. Multiple structured interviews and rating scales were used to evaluate the bereaved group. Those used for this particular study included the parent and child forms of the Diagnostic Interview for Children and Adolescents ( 1 7). These are structured interviews to establish the presence on absence of psychiatric diagnoses for the child on the basis of DSM-III criteria. For the purposes of this study, all subjects were asked all depression questions from this diagnostic interview regardless of whether they answered yes to the four cardinal questions at the beginning of the section that assesses depressive symptoms. The parents of the bereaved chil-
1537
DEPRESSION
IN
BEREAVED
CHILREN
Symptoms in 38 Bere aved and 38 Depressed Prepubertal Children as Reported by the Children and by Their Parentsa
TABLE 1 . Depressive
Parent and/or Child
Report
Parent
Depressed
Bereaved
Depressed
Children
Children
Children
Children
N
%
N
%
N
Dysphoria Lossofinterest Appetite disturbance Sleep disturbance Psychomotor agitation Fatigue
20 13 8 II 12 3
53 34 21 29 32 8
31 21 22 28 25 18
82’ 55
21
29
76d
18
Guilt/worthlessness
8
Trouble
2
thinking
Morbid/suicidal ideation Diagnosis of major depressive (DSM-III-R criteria)
episode
GAll comparisons
bereaved
are
between
Child
Bereaved
Item
or retardation
Report
S
29
76
23
26
17
37
8 2
21
66’
4
47d
1 6 3 11 3
18
47
29
47 76
10
26
28
74
S
14
8
26
68 37 68
11
13
34e
3 16 8 29
20 21 16 24
53d
42 63
8
25
66
depressed
children
N
%
61
36
95’
12
45 24 32
32 26 35
84c 68c 92c
14
37
14 S
37
29 29 32
76 76c 84c
23
13 61
25 34
66 89
14
37
36
95C
9
55d
f and
Children
%
14
74d
Depressed
Children
N
N
58b
Bereaved
%
%
Report
f
by McNemar’s
test.
b
